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THE ATLAS OF 

HEART DISEASE 

AND STROKE 





DR JUDITH MACKAY AND DR GEORGE A. MENSAH 




Published by the WORLD HEALTH ORGANIZATION 

in collaboration with the CENTERS FOR DISEASE 

CONTROL AND PREVENTION 




The Atlas of 

Heart Disease 

and Stroke 




World Health Organization 
Geneva 



In the same series: 




The Tobacco Atlas 




Inheriting the World: 
The Atlas of Children's Health and the Environment 



The Atlas of 

Heart Disease 

and Stroke 

Dr Judith Mackay and Dr George A. Mensah 



Wl 



ith 



Dr Shanthi Mendis and Dr Kurt Greenlund 




World Health Organization 

o 

Geneva 



The Atlas of Heart Disease and Stroke World Health Organization 2004 
All rights reserved 

O 

First published 2004 
1 3 5 7 9 10 8 6 4 2 

WHO Library Cataloguing-in-Publication Data 

Mackav, Judith. 
The atlas of heart disease and stroke / Judith Mackay and George Mensah; 

with Shanthi Mendis and Kurt Greenlund. 

1 .Heart diseases - epidemiology 2 . Cerebrovascular accident epidemiology 

3. Risk factors 4. Atlases I. Mensah, George. II. Mendis, Shanthi. 

III. Greenlund, Kurt. IV.Title. 

ISBN 92 4 1562768 
(NLM Classification: WG 210) 

Produced for the World Health Organization by 

Myriad Editions Limited 

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Coordinated for Myriad Editions by Candida Lacey 

Edited by Hayley Ann 

Design and graphics by Corinne Pearlman 

Maps created by Isabelle Lewis 



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Printed and bound in Honp Kong. China 

o o 7 

Produced through Phoenix Offset Limited under the supervision of Bob Cassels, The Hanway Press, London 



Contents 



Foreword 

by Dr LEE Jong- Wook, Director-General, World Health Organization 9 

Preface 1 1 

Acknowledgements 12 

About the authors 1 5 



CARDIOVASCULAR DISEASE 16 

Types of cardiovascular disease 18 

Different types of cardiovascular diseases. Global deaths from 
cardiovascular diseases. 

Rheumatic fever and rheumatic heart disease 20 

Deaths from rheumatic heart disease. Cases of rheumatic heart 
disease in children. Deaths among Aboriginal and non- 
Aboriginal populations in Australia. 



Part Two: RISK FACTORS 22 

Risk factors 24 

Overview of modifiable, non-modifiable and "novel" risk 
factors. Percentage contribution of leading risk factors to 

o o 

disease burden. Contributory factors in coronary heart disease 
and ischaemic stroke. 

Risk factors start in childhood and youth 26 

Tobacco use in youth. Overweight youth. Over weight trends 
in the USA. 

Risk factor: blood pressure 28 

Average systolic blood pressure worldwide. Trends of high 
blood pressure in USA and India. Changes in blood pressure 
with age in Gambia, and with education in South Africa. 

Risk factor: lipids 30 

Cholesterol levels in women worldwide. Trends in cholesterol 
levels in Beijing, China. Current recommended lipid levels. 

Risk factor: tobacco 32 

Smoking rates worldwide. Cardiovascular risks of smoking and 
passive smoking. Smokers' lack of knowledge of the risks. 



Risk factor: physical inactivity 34 

Physical activity levels: energy expenditure in work, leisure and 
transport. Time spent seated. Various physical activities with 
similar health benefits. Physical inactivity by social class in India. 
Participation in sport in Singapore. Motor vehicle ownership 
and trends. Ratio of bicycles to cars in China and USA. 

9 Risk Factor: obesity 36 

Average adult body mass index (BMI) worldwide. Food 
consumption trends. Apple shape at higher risk of CVD 
than pear shape. 

10 Risk factor: diabetes 38 

Prevalence of diabetes worldwide. Diabetes trends to 2030. 

1 1 Risk factor: socioeconomic status 40 

Socioeconomic influences on cardiovascular risk factors and 
diseases. Education, income levels and occupation in Canada, 
China, India, Italy, Saudi Arabia, South Africa, Trinidad and 
Tobago, Uganda and USA. 

o ' o 

12 Women: a special case? 42 

Similar and different risks in women compared with men. 
Smoking, physical activity and hormone replacement therapy. 



Part Three: THE BURDEN 44 

1 3 Global burden of coronary heart disease 46 

Healthy years of life lost to coronary heart disease. Leading 
causes of disease burden by sex. 

14 Deaths from coronary heart disease 48 

Deaths from coronary heart disease. Comparison with other 
causes of death. Trends in coronary heart disease. 

1 5 Global burden of stroke 50 

Healthy years of life lost to stroke. Stroke in young people. 
Risks of the oral contraceptive pill. 

16 Deaths from stroke 52 

Deaths from stroke. Predictors of death from stroke in Italy. 
Comparison with other causes of death. 



Economic costs 54 

Cost of cardiovascular diseases and their risk factors in selected 

countries, regions and worldwide. Price of medications 

o 

compared with cheapest crop available. Lifetime costs of 
coronary heart disease. Expenditure on cardiovascular 
medications. Cost of risk factors. 



Part Four: ACTION 56 

18 Research 58 

Number of publications on cardiovascular research by country. 
Regional research. Clinical trials on humans: cardiovascular 
disease compared with other health problems. Research funding 
in the USA: CVD compared with other diseases. 

Organizations 60 

International and regional organizations involved with 

o o 

cardiovascular disease. World conferences on cardiovascular 
diseases. 

Prevention: personal choices and actions 62 

Personal choices in lifestyles and behaviours in children, 
adolescents and adults: stopping smoking, eating more fruit and 
cereals, reducing salt intake, physical activity, and prevention 
and control of obesity and high blood pressure. 

Prevention: population and systems approaches 64 

Noncommunicable disease prevention and control. Availability 
of basic equipment, medical professionals, and availability, 
affordability, and local manufacture of drugs. Use of 
medications in stroke and coronary heart disease. Profiles of 
Finland, Japan, Mauritius and New Zealand. Dieticians in the 
United Kingdom promote healthy eating. 

Health education 66 

World Heart Day participation, themes and trends. Medical 
activities, physical activities and promotion of healthy diet. 
Giving up smoking: the International Quit and Win campaign. 

Policies and legislation 68 

Smoke-free government buildings and private workplaces. The 
first five countries to ratify the WHO Framework Convention 
on Tobacco Control (FCTC). National plans for CVD 
prevention and control. Tobacco, food and nutrition legislation. 
Smoking ban in the USA led to reduction in heart attacks. 



24 Treatment 70 

Medication, devices, and operations. Simple secondary 
prevention. Proportion of patients reaching blood pressure and 
cholesterol treatment goals. Participation in cardiac 
rehabilitation. Proportion of people with diabetes treated with 
medication or diet. Trends in cardiovascular operations and 
procedures in the USA. 



Part Five: THE FUTURE AND THE PAST 72 

The future 74 

Predictions to 2030 of the cardiovascular disease epidemic, risk 
factors, economic costs, research, UN Conventions, technology 
and treatment. 

Milestones in knowledge of heart and vascular disorders 

History of key events, developments and research, including 
epidemiology, risk factors, economic costs, inventions and 
interventions. 

BCE-1852 76 

1856-1967 78 

1969-2004 80 



Part Six: World Tables 82 

World data tables 84 

Glossary 92 

Sources 94 

Useful contacts 109 

Index 1 1 1 



Foreword 




A message from 

Dr LEE Jong-Wook 

Director- General 

World Health Organization 

O 

11 cart disease and stroke are currently the leading cause of death in all developed countries and in most developing 
countries. There were approximately 17 million deaths due to cardiovascular disease in 2003 one-third of all 
deaths in the world. 

It is disturbing to note that at least 75% of deaths from heart disease and stroke now occur in the poorer regions 
of the world, which also face major threats from communicable diseases. These regions thus suffer under the so- 
called "double burden" of disease. If preventive action is not taken urgently, heart disease and stroke which are 
already major public health problems will rapidly advance across regions and social classes to reach epidemic 
proportions worldwide. 

We know that the major risk factors for heart disease and stroke are high blood pressure, high blood cholesterol, 
tobacco use, physical inactivity, unhealthy diet and obesity. Many of these risk factors result from unhealthy lifestyles. 
These unhealthy lifestyle habits, which are linked to urbanization, often start in childhood and youth, encouraged by 
the influence of mass advertising and social pressures. This underscores the importance of targeting children and 
young people in all programmes that aim to prevent heart disease and stroke. 

Prevention and control of heart disease and stroke in developing countries represent a challenging task. There are 
a number of major barriers to progress, including lack of reliable epidemiological information, inaccessibility of 
health care, shortages of trained manpower and resources, and misconceptions about heart disease and stroke among 
policy-makers and the public. 

However, the good news is that knowledge about the causes of heart disease and stroke is growing, and various 
countries are gaining experience in translating this knowledge into effective action. 

I believe that our efforts to control heart disease and stroke can only succeed if they are focused at country level. 
Current WHO activities in this area are based on the WHO Global Strategy for the Prevention and Control of 
Noncommunicable Disease, which was adopted by the World Health Assembly in 2000. Our goals are to: 

provide guidance to countries on policy, legislative and financial measures 
that can help prevent cardiovascular disease; 

assess and track the magnitude of the cardiovascular disease epidemic and its 
social, economic, behavioural and political determinants in developing countries; 

reduce cardiovascular risk factors and their determinants and promote 
cardiovascular health for all age groups; 

strengthen the health care of people with cardiovascular disease by developing 
norms and guidelines for cost-effective interventions. 



To achieve these goals, WHO has developed standardized approaches to strengthen national surveillance systems 
for key risk factors. Further, WHO has initiated programmes at country level to scale up health care for those with 
established cardiovascular disease and to introduce affordable and innovative approaches for managing cardiovascular 
risk factors and cardiovascular disease in low-resource settings. 

WHO is also in the process of addressing some of the main risk factors for cardiovascular disease through global 
action, such as the Framework Convention on Tobacco Control and the Global Strategy on Diet, Physical Activity 
and Health. These strategies will help countries in their efforts to develop and implement policies to reduce the 
burden of cardiovascular disease. 

We recognize that advocacy, resource mobilization, capacity development, and research are necessary to galvanize 
global action against the causes of cardiovascular disease. WHO is working with other UN agencies, research 
institutions, nongovernmental organizations, the private sector and civil society to promote these activities. Together 
we can move the global public health agenda forward to avert unnecessary deaths and suffering due to this eminently 
preventable disease. 




10 



Preface 



"We have the scientific knowledge to create a world 

in which most heart disease and stroke could be eliminated." 

The Victoria Declaration on Heart Health, 1992 

"Change before you have to." 
Jack Welch, 

former Chairman and Chief Executive Officer of 
General Electric, USA (193 5-) 



lleart disease and stroke, the main cardiovascular diseases, are truly global epidemics. They deserve the attention 
of governments, policy-makers, national and international organizations, committed individuals and families 
everywhere. 

Heart disease and stroke are no longer diseases of old men in developed countries. They are also diseases of 
women, young adults, and even children. They affect the wealthy and the poor. Already they claim more lives in 
developing than developed countries. The Asian girl on the cover is at risk, as are many children and young adults 
throughout the world. 

o 

The risk factors for heart disease and stroke begin in youth, and most can be prevented or controlled. Yet, 
worldwide, most people who have risk factors are either not treated or are inadequately treated. Special attention to 
high blood pressure, high blood cholesterol, tobacco and other major risk factors is crucial. 

Cardiovascular diseases are more than just health problems: both the diseases and their underlying causes have 
major financial implications for governments, businesses and individuals. The "globesity" epidemic is causing 
international concern. The tobacco epidemic is linked to smuggling, big business and politics. If people are to be 
encouraged to take regular physical activity, commitment is needed from both individuals and society. The 
prevention and control of high blood pressure and high blood cholesterol require action from governments and the 
pharmaceutical industry, not just individual patients. 

Research achievements in the field of heart disease and stroke have been phenomenal. We know a lot today, but as 
Goethe put it, "knowing is not enough, we must apply." We must apply what we already know, and translate the best 
science into practice for the benefit of all, worldwide. 

The good news, as stated most eloquently in the Victoria Declaration on Heart Health more than a decade ago, is 
that we know what we need to do to eliminate most heart disease and stroke. What is needed now is the 
combination of necessary resources and political will on a global scale to take effective action. Now is the time to act 
and to change before we have to. 



Judith Mackay, Hong Kong SAR, China 
George A. Mensah, Atlanta, GA, USA 



11 



Acknowledgements 



Special thanks go to the following WHO staff for their 
support for this project: Catherine Le Gales-Camus, 
Assistant Director-General, Noncommunicable Diseases 
and Mental Health; Robert Beaglehole, Director, 
Department of Chronic Diseases and Health Promotion; 
Rafael Bengoa, Director, Health Systems Policy and 
Operations; and Derek Yach, Representative of the 
Director-General. 

Particular thanks go to the Centers for Disease 
Control and Prevention (CDC), United States of 
America, for their generous financial support of this 
atlas. 

For their creativity, artistic talent and innovative 
suggestions in the design and cartography of this atlas, 
we would like to thank the Myriad Editions team of 
Candida Lacey, Corinne Pearlman, Hay ley Ann and 
Isabelle Lewis. 

Sincere thanks go to Pat Butler for her editorial input, 
and to all colleagues at the World Health Organization: 
Dele Abepunde, Technical Officer, Cardiovascular 

O 

Diseases, Noncommunicable Diseases and Mental Health; 

Timothy Armstrong, Technical Officer, 
Surveillance and Information for Policy, 
Noncommunicable Diseases and Mental Health; 

Vishal Arora, Noncommunicable Diseases and 
Mental Health, South East Asia Region (SEARO); 

Fabienne Besson, Secretary, Management of 
Noncommunicable Diseases, Noncommunicable 
Diseases and Mental Health; 

Ties Boerma, Director, Measurement and Health 
Information Systems, Evidence and Information for 
Policy; 

Ruth Bonita, Director, Surveillance, Office of 
Assistant Director- General, Evidence and Information 
for Policy; 

Gian Luca Burci, Senior Legal Officer, Office of 
the Legal Counsel; 

Somnath Chatter] i, Scientist, Classification, 
Assessment, Surveys and Terminology, Evidence and 
Information for Policy; 

Charles Gollmar, Group Leader, School Health 
and Youth Health Promotion, Noncommunicable 
Diseases and Mental Health; 

Carina Marquez, Technical Officer, Surveillance 
and Information for Policy, Noncommunicable Diseases 
and Mental Health; 

Colin Mathers, Scientist, Epidemiology and 

12 



Burden of Disease, Evidence and Information for Policy; 

Shanthi Mendis, Coordinator, Cardiovascular 
Diseases, Noncommunicable Diseases and Mental 
Health; 

Patricia Mucavele, Technical Officer, Nutrition for 
Health and Development, Noncommunicable Diseases 
and Mental Health; 

Mona Nassef, Secretary, Cardiovascular Diseases, 
Noncommunicable Diseases and Mental Health; 

Chizuru Nishida, Scientist, Nutrition for Health 
and Development, Noncommunicable Diseases and 
Mental Health; 

Tomoko Ono, Technical Officer, Surveillance and 
Information for Policy, Noncommunicable Diseases and 
Mental Health; 

Leanne Riley, Scientist, School Health and Youth 
Health Promotion, Noncommunicable Diseases and 
Mental Health; 

Gojka Roglic, Technical Officer, Diabetes 
Mellitus, Noncommunicable Diseases and Mental 
Health; 

Jukka Sailas, Scientist, Management Support 
Unit, Evidence and Information for Policy, 
Noncommunicable Diseases and Mental Health; 

Bakuti Shengelia, Medical Officer, Cardiovascular 
Diseases, Noncommunicable Diseases and Mental 
Health; 

Kate Strong, Acting Team Coordinator, 
Surveillance and Information for Policy, 
Noncommunicable Diseases and Mental Health; 

Bedirhan Ustun, Coordinator, Classification, 
Assessment, Surveys and Terminology, Evidence and 
Information for Policy; 

Pierre-Michel Virot, Audiovisual and Training 
Team, Information Technology and Telecommunications; 

Amalia Waxman, Project Manager, 
Noncommunicable Diseases and Mental Health. 

Thanks to our colleagues at the National Center for 
Chronic Disease Prevention and Health Promotion, 
Centers for Disease Control and Prevention (CDC), 
United States of America: 

Laurie D. Elam-Evans, Deputy Associate Director 
for Science, Division of Adult and Community Health; 

Wayne H. Giles, Associate Director of Science, 
Division of Adult and Community Health; 

Kurt J. Greenlund, Senior Epidemiologist, 
Science and Communication Unit, Cardiovascular Health 



Branch, Division of Adult and Community Health; 

Mary E. Hall, Public Health Analyst, Office of the 
Director; 

Virginia Bales Harris, Director, Division of Adult 
and Community Health; 

Marsha L. Houston, Health Communication 
Specialist, Cardiovascular Health Branch, Division of 
Adult and Communitv Health; 

Frederick L. Hull, Deputy Chief, Technical 
Information and Editorial Services Branch, Office of the 
Director; 

Margaret Malone, Deputy Chief, Cardiovascular 
Health Branch, Division of Adult and Community 
Health; 

James S. Marks, Director. 

For their input on particular maps and subjects, we 
would like to thank the following: 

4 Risk factors start in childhood and youth 
Samira Asma, Associate Director, Global Tobacco 
Control, Office on Smoking and Health, Centers for 
Disease Control and Prevention, USA; Jonathan R. 
Carapetis, Consultant in Paediatric Infectious Diseases, 
Centre for International Child Health, University of 
Melbourne, Australia; Gilles Paradis, Division of 
Preventive Medicine, McGill University Health Center, 
Montreal, Canada; Neville Rigby, Director of Policy and 
Public Affairs, International Obesity TaskForce, 
International Association for the Study of Obesity; 
Charles W. Warren, Distinguished Consultant 
/Demographer, Global Tobacco Control, Office on 
Smoking and Health, Centers for Disease Control and 
Prevention, USA. 

5 Risk factor: blood pressure Yussuf Saloojee, 
tobacco control advocate, South Africa. 

6 Risk factor: lipids Robert Clarke, Clinical Trial 
Service Unit, Oxford University, United Kingdom; Rory 
Collins, Clinical Trial Service Unit, Oxford University, 
United Kingdom. 

o 

7 Risk factor: tobacco Omar Shafey, Manager, 
International Tobacco Surveillance, American Cancer 
Society, USA. 

8 Risk factor: physical inactivity Krishnan Anand, 
Associate Professor, Centre for Community Medicine, 
All India Institute of Medical Sciences, India. 

12 Women: a special case? Sandra Coney, women's 

health advocate, New Zealand. 

18 Research Rory Collins, Clinical Trial Service Unit, 



Oxford University, United Kingdom; Hugh Tunstall- 
Pedoe, Cardiovascular Epidemiology Unit, University of 
Dundee, United Kingdom (MONICA study). 
19 Organizations Children's Heart Link (USA): Karen 
Baumgaertner, International Programs Associate; John 
Gushing, International Programs Director. International 
Association for the Study of Obesity: Neville Rigby, Director 
of Policy and Public Affairs, International Obesity 
TaskForce. International Stroke Society: Julien 
Bogousslavsky, President-Elect; Frank M. Yatsu, 
Treasurer. World Heart Federation: Carola Adler, World 
Heart Day Manager; Sara Bowen, Website /IT Manager; 
Sania Nishtar, Chairman, World Heart Day Committee; 
Philip Poole-Wilson, President; Janet Voute, Chief 
Executive Officer. 

22 Health education World Heart Federation (as 
above); Eeva Riitta Vartiainen, Project Manager, 
International Quit and Win, Finland. 

23 Policies and legislation Omar Shafey, Manager, 
International Tobacco Surveillance, American Cancer 
Society, USA. 

25 The future Rory Collins, Clinical Trial Service 
Unit, Oxford University, United Kingdom; Anthony 
Rodgers, Clinical Trials Research Unit, University of 
Auckland, New Zealand. 

26 Chronology Julien Bogousslavsky, President-Elect, 
International Stroke Society; Rory Collins, Clinical Trial 
Service Unit, Oxford University, United Kingdom; John 
W. Farquhar, Stanford Prevention Research Center, 
USA; David Simpson, International Agency on Tobacco 
and Health, London, United Kingdom. 

We are also extremely grateful to our families for their 
support during the preparation of this atlas. 

For the use of photographs, we would like to thank the 

following: 

Front cover Amy, Hong Kong Guy Nowell, Hong 

Kong SAR, China, http://www.guynowell.com 

Back cover photographs Cardiology operation, 

Mauritius WHO /Harry Anenden; man selling 

vegetables, India WHO /Pierre Virot; man on bench 

iStock/Tomaz Levstek; Woman and girl buying 

sweets, India WHO/Pierre Virot 

Part 1 Child health examination, Cuba 

WHO /Carlos Gaggero 

Part 2 Woman cooking, Guatemala WHO/Armando 

Waak 

13 



Part 3 Cardiology operation, USA WHO/Jean 

Mohr 

Part 4 Youth sport, Germany WHO/Tibor Farkas 

Part 5 Adolescent group, Peru WHO /Julio Vizcarra 

Part 6 Man selling vegetables, India WHO/Pierre 

Virot 

I Types of cardiovascular disease Heart Hemera 
Photo-Objects 

4 Risk factors start in childhood and youth Boy 

smoking, Seychelles WHO/Harry Anenden; burger 
Hemera Photo-Objects 

6 Risk factor: lipids Arteries American Heart 
Association; rice bowl Hemera Photo-Objects 

7 Risk factor: tobacco Smoking hand; young people, 
Canada WHO/J L Ray; road signs, USA Corinne 
Pearlman 

8 Risk factor: physical inactivity TV viewer, biker, 
wheelchair user, woman with push-chair Hemera 
Photo-Objects; people on scooter, New Delhi 
Candida Lacey 

9 Risk factor: obesity Groceries, USA USDA/ 
Ken Hammond; apple and pear Woodrow Phoenix/ 
Comic Company /British Dietetic Association 

10 Risk factor: diabetes Men playing basketball, 
Finland WHO /Farkas Tibor 

I 1 Risk factor: socioeconomic status Young boy 
smoking, China Carol Betson 

12 Women: a special case? Hospital patient, Finland 
WHO/Tibor Farkas; smoking woman iStock/ 
Tan Kian Khoon; obese woman iStock/Annette 
Birkenfeld; women walking iStock/ Leah- Anne 
Thompson; menopausal woman iStock/Joseph Jean 
Rolland Dube 

13 Global burden of coronary heart disease 
Cardiology operation, Mauritius WHO/Harry 
Anenden 



14 Deaths from coronary heart disease 

Cardiology operation, USA WHO/Jean Mohr; heart 
Hemera Photo-Objects 

15 Global burden of stroke Pills iStock/ Amanda 
Rohde 

16 Deaths from stroke Man on bench iStock/ 
Tomaz Levstek 

17 Economic costs Rice USDA /Ken Hammond; 
potatoes USDA/Ken Hammond 

19 Organizations WHO HQ Geneva 
WHO/Pierre Virot 

20 Prevention: personal choices and actions 
Salad, USA Corinne Pearlman; Amv, Hong Kong 

J ' O O 

Guy Nowell; grapefruit, runner Hemera Photo- 
Objects 

21 Prevention: population and systems 
approaches Good Heart Food leaflet British 
Dietetic Association/ Comic Company; hospital 
computer, UK WHO/P Larsen; health examination 
WHO /Julio Vizcarra 

22 Health Education Posters World Heart 
Federation 

23 Policies and legislation Singapore bus WHO/ 
Tibor Farkas; display, gymnasium, Singapore, WHO; 
fried food, USA (bar chart) Corinne Pearlman; man 
smoking, Sri Lanka (bar chart) Garrett Mehl; burger 
Hemera Photo-Objects 

24 Treatment Man on bike, Finland WHO/Tibor 
Farkas 

25 The future Woman, Rwanda WHO/J. L. Ray 



Whilst every reasonable effort has been made to contact 
the copyright holders of images used in the atlas, the 
authors and publisher will gladly receive information 
that will enable them to rectify any inadvertent errors in 
subsequent editions. 



14 



About the authors 




Dr Judith Mackay 
MBChB, FRCP (Edin), FRCP (Eng) 

Dr Judith Mackay is a medical doctor based in Hong 

Kong Special Administrative Region, China, and a 

Senior Policy Adviser to the World Health Organization. 

After an early career as a hospital physician, she became 

a health advocate. She is a Fellow of the Royal Colleges 

of Physicians of Edinburgh and of London, and an 

Honorary Fellow of the Hong Kong College of 

Cardiology. Dr Mackay has received many international 

awards, including the WHO Commemorative Medal, 

the Fries Prize for Improving Health, the Luther Terry 

Award for Outstanding Individual Leadership, the 

International Partnering for World Health Award, and 

the Founding International Achievement Award from the 

Asia Pacific Association for the Control of Tobacco. 

She is the author of The Tobacco Atlas, The State of Health 

Atlas and The Penguin Atlas of Human Sexual Behavior. 




Dr George A. Mensah 
MD, FACC, FACP, FESC 

Dr George Mensah is acting director, the National 

Center for Chronic Disease Prevention and Health 

Promotion, and chief of the Cardiovascular Health 

Branch at the Centers for Disease Control and 

Prevention in Atlanta, Georgia, USA, and clinical 

professor of medicine and cardiology at the Medical 

College of Georgia. He is a fellow of the American 

College of Cardiology, American Heart Association, 

and the European Society of Cardiology, and a 

foundation fellow of the Ghana College of Physicians 

and Surgeons. Recent honours include the 

Distinguished Research Award of the International 

O 

Society of Hypertension in Blacks, the 25th Bernard 

Pimstone Memorial Lecturer at the University of Cape 

Town in South Africa, and the National Heart 

Foundation of Australia Lecturer at the 

50th Anniversary Celebration of the Cardiac 

Societies of Australia and New Zealand. 



15 










16 



PART 1 

CARDIOVASCULAR DISEASE 




"When man is serene, the pulse of the heart flows and connects, 
just as pearls are joined together or like a string of red jade, 

then one can talk about a healthy heart." 

17 

The Yellow Emperor's Canon of Internal Medicine, 2500 BCE 



1 



"All the knowledge I possess everyone else 

can acquire, but my heart is all my own." 

Johann Wolfgang von Goethe 

The Sorrows of Young Werther 1774 

The human heart is only the size 
of a fist, but it is the strongest 
muscle in the human body. 

The heart starts to beat in the 
uterus long before birth, usually 
by 21 to 28 days after conception. 
The average heart beats about 

O 

1 00 000 times daily or about two 
and a half billion times over a 
70 year lifetime. 

With every heartbeat, the heart 
pumps blood around the body. It 
beats approximately 70 times a 
minute, although this rate can 

O 

double during exercise or at times 
of extreme emotion. 

Blood is pumped out from the 
left chambers of the heart. It is 
transported through arteries of 
ever-decreasing size, finally 
reaching the capillaries in all the 
tissues, such as the skin and other 
body organs. Having delivered its 
oxygen and nutrients and having 
collected waste products, blood is 
brought back to the right 

O O 

chambers of the heart through a 
system of ever-enlarging veins. 
During the circulation through 
the liver, waste products are 
removed. 

This remarkable system is 
vulnerable to breakdown and 
assault from a variety of factors, 
many of which can be prevented 
and treated. Risk factors will be 
explored on pages 24 43. 



Types of cardiovascular 
disease 



2 265 824 



Deaths from cardiovascular diseases (CVD) 

Number of deaths globally per year 
from different types of CVD, 

b Y age / 1868 339 

Highest numbers shown 

2002 



coronary heart disease 

stroke 

other cardiovascular diseases 

hypertensive heart disease 

inflammatory heart disease 

rheumatic heart disease 




996 183 



280819 



104 116 



66542 



0-4 years 5-14 15-29 30-44 45-59 60-69 70-79 80+ years 



Global deaths from CVD 

millions 

2002 

total deaths: 16.7 million 



other forms of 

heart disease 

2.4m 



inflammatory 
heart disease 
0.4m 

hypertensive 
heart disease 
0.9m 


rheumatic 
heart disease 
0.3m 



18 




coronary heart disease 
7.2m 



Coronary heart disease 

Disease of the blood vessels 

supplving the heart muscle. 

Major risk factors High blood pressure, 

high blood cholesterol, tobacco use, 

unhealthy diet, physical inactivity, 

diabetes, advancing age, inherited 

(genetic) disposition. 

Other risk factors Poverty, low educational 

status, poor mental health (depression), 

inflammation and blood clotting disorders. 

Rheumatic heart disease 

Damage to the heart muscle and heart 
valves from rheumatic fever, caused by 
streptococcal bacteria. J ^ 



Congenital heart disease 

Malformations of heart structures 
existing at birth may be caused bv 

o -* * 

genetic factors or by adverse 

exposures during gestation. 

Examples are holes in the 

heart, abnormal valves, 

and abnormal heart 

chambers. 

Riskfactors 

Maternal alcohol 

use, medicines 

(for example 

thalidomide, warfarin) used by the expectant 

mother, maternal infections such as rubella, 

poor maternal nutrition (low intake of folate), 

close blood relationship between parents 

(consanguinity). 

Other cardiovascular diseases 

Tumours of the heart; vascular tumours of the 
brain; disorders of heart muscle 
(cardiomyopathy); heart valve diseases; 
disorders of the lining of the heart. 

Other factors that can damage 
the heart and blood vessel system 

Inflammation, drugs, high blood pressure, 
unhealthy diet, trauma, toxins and alcohol. 



Stroke 

Strokes are caused by disruption of the blood supply to the 

brain. This may result from either blockage (ischaemic 

stroke) or rupture of a blood vessel (haemorrhagic stroke). 

Riskfactors High blood pressure, atrial fibrillation (a heart 

rhythm disorder), high blood cholesterol, tobacco use, 

unhealthy diet, physical inactivity, diabetes, 

and advancing age. 





Aortic aneurysm and 
dissection 

Dilatation and rupture 
of the aorta. 

Riskfactors Advancing age, long- 
L standing high blood pressure, 
Mar fan syndrome, 
congenital heart disorders, 

o 

syphilis, and other 
infectious and 
inflammatory 
disorders. 



Peripheral arterial disease 

Disease of the arteries 
supplying the arms and legs. 
Riskfactors As for 
coronary heart disease. 

Deep venous thrombosis (DVT) 
and pulmonary embolism 

Blood clots in the leg veins, 
which can dislodge and move to the 

O 

heart and lungs. 

Riskfactors Surgery, obesity, cancer, 
previous episode of DVT, recent 
childbirth, use of oral contraceptive and 
hormone replacement therapy, long 
periods of immobility, 
for example while travelling, high 
homocysteine levels in the blood. 

19 



Rheumatic fever usually follows 
an untreated beta-haemolytic 
streptococcal throat infection in 
children. It can affect many parts 
of the body, and may result in 
rheumatic heart disease, in which 
the heart valves are permanently 
damaged, and which may progress 
to heart failure, atrial fibrillation, 
and embolic stroke. 

Nowadays, rheumatic fever 
mostly affects children in 
developing countries, especially 
where poverty is widespread. Up 
to 1 % of all schoolchildren in 
Africa, Asia, the Eastern 
Mediterranean region and Latin 
America show signs of the 

o 

disease. 

Of 1 2 million people currently 
affected by rheumatic fever and 
rheumatic heart disease, two- 
thirds are children between 
5 and 15 years of age. There are 
around 300 000 deaths each year, 
with two million people requiring 
repeated hospitalization and one 
million likely to require surgery 
in the next 5 to 20 years. 

Early treatment of 
streptococcal sore throat can 
preclude the development of 
rheumatic fever. Regular long- 
term penicillin treatment can 
prevent rheumatic fever 
becoming rheumatic heart 
disease, and can halt disease 
progression in people whose heart 
valves are already damaged by the 
disease. In many developing 
countries, lack of awareness of 
these measures, coupled with 
shortages of money and 
resources, are important barriers 
to the control of the disease. 



Rheumatic fever and 
rheumatic heart disease 




EL SALVADOI 

COSTA Rl 



I(JRAS ST KinS a NEVIS | ANTIGUA a BARBUDA 

ST VINCENT a GRENADINES (5 ST LJ ^ A A 

.i^f GRENADA o O BARBADOS 

01%^* ^H '^TRINIDAD a TOBAGO 

PANAMA^! VENEZUELA miYAN;A 

COLOMBIA 



MA 

CAPE VERDE 

SEr 
GAMBIA 

GUINEA-BISSAL 
SIERRA 



Deaths from rheumatic fever and 
rheumatic heart disease in the Aboriginal * 
and non-Aboriginal populations of Australia 




1979-1996 



Average age at death 

Aboriginal 
population 3 

non-Aboriginal 
population 



Percentage of deaths 



67 Y ears 




20 



Deaths from rheumatic heart disease 



Number of deaths 


2002 











10 000 and above 


H 500-999 


0-9 





5000-9999 


100-499 


no data 


1 


1000-4999 


| 10-99 





H EA YEMEN 

oun 



5 

^jyr KENYA 

DEM. REP. RIVANDA 



Rheumatic heart disease in children 

Estimated number of cases in 5 to 14-year-olds 
reported 2003 



136971 153679 




Sub-Saharan 

Africa 



China South-Central Asia 
Asia (other) 



Latin America Eastern Eastern 

Mediterranean Europe 
and North Africa 



Pacific Developed 

countries 



21 



/* 






PART 2 



RISK FACTORS 







"He that eats but one dish seldom needs the doctor." 

Old Scottish proverb 



23 



"The gods are just, and of our pleasant vices 

Make instruments to plague us." 

King Lear, V.iii. 193 William Shakespeare 

(1564-1616) 

Over 300 risk factors have been 
associated with coronary heart 
disease and stroke. The major 
established risk factors meet three 
criteria: a high prevalence in many 
populations; a significant 
independent impact on the risk of 
coronary heart disease or stroke; 
and their treatment and control 
result in reduced risk. 

Risk factors for cardiovascular 
disease are now significant in all 
populations. In the developed 
countries, at least one-third of all 
CVD is attributable to five risk 
factors: tobacco use, alcohol use, 
high blood pressure, high 
cholesterol and obesity. 

In developing countries with low 
mortality, such as China, 
cardiovascular risk factors also 
figure high on the top 10 list. 
These populations face a double 
burden of risks, grappling with the 
problems of undernutrition and 
communicable diseases, while also 
contending with the same risks as 
developed nations. 

Even in developing countries 
with high mortality, such as those 
in sub-Saharan Africa, high blood 
pressure, high cholesterol, tobacco 
and alcohol use, as well as low 
vegetable and fruit intake, already 
figure among the top risk factors. 

Some major risks are modifiable 
in that they can be prevented, 
treated, and controlled. There are 
considerable health benefits at all 
ages, for both men and women, in 
stopping smoking, reducing 
cholesterol and blood pressure, 
eating a healthy diet and increasing 
physical activity. 

24 



Risk factors 




high blood pressure 
tobacco use 
high cholesterol 




Leading risk factors 

As percentage burden of all diseases 
2002 

major CVD risk factors 
other risk factors 




10.2% unsafe sex 

5.5% unsafe water, sanitation ft hygiene 
indoor smoke from solid fuels 
3.2% zinc deficiency 
iron deficiency 
3.0% vitamin A deficiency 





High-mortality developing countrie 




high blood pressure 
tobacco use 
| high cholesterol 

alcohol 
obesity 

low fruit ft vegetable intake 
3.1% underweight 
1 .9% indoor smoke from solid fuels 
1.8% iron deficiency 
1.7% unsafe water, sanitation ft hygiene 




Jjsjr * 
Low-mortality developing countrie 




9% high blood pressure 

12.2% tobacco use 
7.6% high cholesterol 
9.2% alcohol 
obesity 

I low fruit ft vegetable intake 
[ physical inactivity 
1.8% illicit drug use 
0.8% unsafe sex 
0.7% iron deficiency 





eveloped countrie 



Contributory factors 

Percentage contribution of selected risk factors 
to coronary heart disease and ischaemic stroke 
2002 



62% 



56% 



^p low frui 
physical 

31% 

ll ll. 




M suboptimal systolic 
blood pressure 
more than 115 mmHg 

high cholesterol 
low fruit ft vegetable intake 
inactivity 



coronary heart disease ischaemic stroke 



Major modifiable risk factors 

High blood pressure 

Major risk for heart attack and the most important 
risk factor for stroke. 

Abnormal blood lipids 

High total cholesterol, LDL-cholesterol and 
triglyceride levels, and low levels of HDL- 
cholesterol increase risk of coronary heart disease 
and ischaemic stroke. 

Tobacco use 

Increases risks of cardiovascular disease, especially 
in people who started young, and heavy smokers. 
Passive smoking an additional risk. 

O 

Physical inactivity 
Increases risk of heart disease and stroke by 50%. 



75% 



of 



C 



Obesity 

Major risk for coronary heart 

disease and diabetes. 
Unhealthy diets 

Low fruit and vegetable 

intake is estimated to cause 

about 3 1 % of coronary 

heart disease and 1 1 % of 

stroke worldwide; high saturated fat intake 

increases the risk of heart disease and stroke through 

its effect on blood lipids and thrombosis. 
Diabetes mellitus 

Major risk for coronary heart disease and stroke. 



ely 



ar 



to 



Other modifiable risk factors 

Low socioeconomic status (SES) 

Consistent inverse relationship with risk of heart 
disease and stroke. 

Mental ill-health 

Depression is associated with an increased risk of 
coronary heart disease. 

Psychosocial stress 

Chronic life stress, social isolation and anxiety 
increase the risk of heart disease and stroke. 



Non-modifiable risk factors 

Advancing age 

Most powerful independent risk factor for 
cardiovascular disease; risk of stroke doubles 
every decade after age 55. 
Heredity or family history 
Increased risk if a first-degree blood relative has 
had coronary heart disease or stroke before the 
age of 55 years (for a male relative) or 65 years 
(for a female relative). 



Alcohol use 

One to two drinks per day may lead to a 30% 
reduction in heart disease, but heavy drinking 
damages the heart muscle. 

Use of certain medication 

Some oral contraceptives and hormone 

replacement therapy increase risk of heart disease. 
1 Lipoprotein(a) 

Increases risk of heart attacks especially in 

presence of high LDL-cholesterol. 
Left ventricular hypertrophy (LVH) 

A powerful marker of cardiovascular death. 



1 Gender 

Higher rates of coronary heart disease among men 
compared with women (premenopausal age); risk 
of stroke is similar for men and women. 
1 Ethnicity or race 

Increased stroke noted for Blacks, some Hispanic 
Americans, Chinese, and Japanese populations. 
Increased cardiovascular disease deaths noted for 
South Asians and American Blacks in comparison 
with Whites. 



"Novel" risk factors 

Excess homocysteine in blood 

High levels may be associated with an increase in 

cardiovascular risk. 
Inflammation 

Several inflammatory markers are associated with 

increased cardiovascular risk, e.g. elevated 

O 

C-reactive protein (CRP). 



Abnormal blood coagulation 
Elevated blood levels of fibrinogen and other 
markers of blood clotting increase the risk of 
cardiovascular complications. 



25 



"Encased in fat in youth, encased in a 

coffin in middle age." 

Ancient Chinese proverb 

Although cardiovascular diseases 
typically occur in middle age or 
later, risk factors are determined 
to a great extent by behaviours 
learned in childhood and 
continued into adulthood, such as 
dietary habits and smoking. 

Throughout the world, these 
risks are starting to appear earlier. 
Physical activity decreases 
markedly in adolescence, 
particularly in girls. Obesity has 
increased substantially, not only 
in Europe and North America, 
but also in traditionally slender 
populations such as the Chinese 
and Japanese. Type 2 diabetes was 
previously rare in children, but is 
increasing in adolescents in, for 
example, North America, Japan 
and Thailand. 

Markers of CVD can be seen in 
young children. Post-mortems of 
children who died in accidents 
have found fatty streaks and 
fibrous plaques in the coronary 
arteries. These early lesions of 
atherosclerosis were most 
frequently found in children 
whose risk factors included 
smoking, elevated plasma lipids, 
high blood pressure and obesity. 

Programmes to address 
childhood and youth risk factors 
are mostly confined to developed 
countries, but urgent action is 
required worldwide. Families, 
schools, communities, health 
professionals, public health 
officials and policy-makers all 
need to promote healthy lifestyles 
in children and young people. 
Unless the spread of risk factors is 
stemmed, the world faces an 
epidemic of CVD. 

26 



Risk factors start in 
childhood and youth 



Both sexes aged 6 to 1 1 years 
6.5/o 



Both sexes aged 12 to 19 years 



5.0% 



1 0.5% 




Overweight trends in the USA 

Percentage of young people 
who are overweight 
7976-2000 



Overweight youth 

Percentage of 15-year-olds 
who are overweight 
7997-7998 

selected countries 

5.1% 
W males 




^0 females 



10.8% 



Belgium 
(Flemish) 
zech 
public 
Denmark 




f 




o-o 

RUS5IAN FEDERATION 



CUBA 

MEXICO HK^^^B 

JAMAICA , \ 
BELIZE 

GUATEMALA 'r.^Sft NEVIS 

ELSAIVAOOR \DURAS ST VINCENT ft _ . -SUTJCIA 

COSTA RICA GRENADA nuKMO ft TOBAGO 

PANAMA VENEZUELA GUYANA 

COLOMBl 
F 4 



UNISIA LEBANON' "' ^ IS1 . RE p, 

WEST BANk"*" JORDAN 
LIBYAN AND GAZA 
ARAB 
JAMAHIRIYA EGYPT 



V 





BAHAMAS 
MEXICO CU6 * 

^JAMAICA ^ 7 G ANT'luA >; ftB. ! .B U DA 

GUATEMALA x \ ST POTS fl NEVIS v ^unNTSfRRAI |UK1 
EL SALVADOR hONBURAS S ^J E ^- ST LUCIA 

COSTARICA GRENADA IRINIDAD ft TOBAGO 

PANAMA VENEZUELA GUYANA 

COLOMBIA T SL'RINAME 

ECUADOR 



TUNISIA LEBANON- ISl. REP 

MOROCCO j- IRAN 

WEST BANK JORDAN 
LIBYAN AND GAZA KUWAIT 

ARAB BAHRAIN^ 

JAMAHIRIYA EOYPI 



MAURITl 

' ^ X%v 
SENEGAL 



TANIA 



% 



NIGER 
NIGERIA 




Early starters 

Percentage of students, primarily aged 13 to 15 years, 

using tobacco 

7999-2003 



45% and above 
300/0-44.9% 
15%-29.9% 
below 1 5% 
no data 



. 

^ 



^ ^ . ^ 

I- MYANMAR l ^S 

OO -< 

^J 

CAMBODIA VIETNAM PHILIPPINES 
SRI LANKA PALflu , 



N D N E S 



Girls 



ZIMBABWE 



oooo 

<> URUGUAY 
ARGENTINA 



SWAZILAND 
SOUTH 
AFRICA LESOTHO 



27 



"There are six flavours and, of them all, 

salt is the chief." 

Hindu proverb 

High blood pressure 
(hypertension) is one of the most 
important preventable causes of 
premature death worldwide. 
Even a blood pressure at the top 
end of the normal range increases 
risk. High blood pressure is 
defined as a systolic blood 
pressure (SBP) above 140 mmHg 
and/or a diastolic blood pressure 
(DBF) above 90 mmHg. 

In most countries, up to 30% of 
adults suffer from high blood 

O 

pressure and a further 50% to 
60% would be in better health if 
they reduced their blood 
pressure, by increasing physical 
activity, maintaining an ideal body 
weight and eating more fruits and 
vegetables . 

O 

In people aged up to SO years, 
both DBF and SBP are associated 
with cardiovascular risk; above 
this age, SBP is a far more 
important predictor. Blood 
pressure usually rises with age, 
except where salt intake is low, 
physical activity high, and obesity 
largely absent. 

Most natural foods contain salt, 
but processed food may be high in 
salt; in addition, individuals may 
add salt for taste. Dietary salt 
increases blood pressure in most 
people with hypertension, and in 
about a quarter of those with 
normal blood pressure, especially 
with increasing age. A high intake 
of salt independently increases the 
risk of CVD in overweight 
persons. 

In addition to lifestyle changes, 
effective medication is available 
for control of high blood pressure. 

28 



Risk factor: blood 



pressure 




Black non-Hispanic female 
Black non-Hispanic male 

White non-Hispanic male 



White non-Hispanic female 

Mexican male 125.6 
Mexican female 22. 



igh blood pressure in the USA 

Percentage of people aged 20 to 74 years 
with blood pressure of 140/90 mmHg or above, 
or taking anti-hypertensive medicine, 
age-adjusted 
/ 976-2000 




1988-1994 



1999-2000 



Blood pressure changes with age in the Gambia 

7996-7997 




\ \ 

16-24 26-35 36-45 
years years years 



46-55 56-65 
years years 



66-75 76-100 
years years 



High blood pressure 
by years of education 
HI I in South Africa 

Percentage of people 
aged 15 and above 
with blood pressure 
higher than 
160/95 mmHg 
7998 
female 



Blood pressure in India 

Average systolic blood pressure 

in urban men 

aged 40 to 49 years 

7942-7997 

mmHg 





Average systolic blood pressure of people 
: aged 30 years and above 
estimated to 2005 

mmHg 

data from urban populations only 




Risk factor: lipids 



High levels of LDL-cholesterol, 

o 

and other abnormal lipids (fats), 
are risk factors for cardiovascular 
disease. Cholesterol is a soft, 
waxy substance found among the 
lipids in the bloodstream and in 
all the body's cells. It is needed to 
form cell membranes and 
hormones, and for other bodily 
functions. 

The body can make cholesterol, 
or it can obtain it from food, 
especially animal products such as 
meats, poultry, fish, eggs, and 
dairy products. Certain saturated 
vegetable fats and oils, including 
coconut fat and palm oil, are 
cholesterol -free but cause an 
increase in blood cholesterol. 
Some foods that do not contain 
animal products may contain 
trans-fats, which also cause the 
body to make more cholesterol. 
Fruit, vegetables and cereals do 
not contain cholesterol . 

Cholesterol is transported 
around the body in two kinds of 
lipoproteins: low-density 
lipoprotein, or LDL, and high- 
density lipoprotein, or HDL. 
A high level of LDL can lead to 
clogging of the arteries, 
increasing the risk of heart attack 
and ischaemic stroke, while HDL 
reduces the risk of coronary heart 
disease and stroke. 

The female sex hormone 
estrogen tends to raise HDL- 
cholesterol levels, which may 
help explain why premenopausal 
women are relatively protected 
from developing coronary heart 
disease. 




Current recommended lipid levels 

European guideline 

less than 5.0 mmol/l 
less than 3.0 mmol/l 



Total cholesterol 

LDL-cholesterol 

HDL-cholesterol 



US guideline 

less than 240 mg/dl (6.2 mmol/l) 

less than 160 mg/dl (3.8 mmol/l) 



1.0 mmol/l or more in males 40 mg/dl (1 mmol/l) or more 
1.2 mmol/l or more in females 



Triglycerides (fasting) less than 1.7 mmol/l 



less than 200 mg/dl (2.3 mmol, 



30 



Cholesterol 



Average cholesterol levels in women aged 30 and above 

mmol/litre 

estimated to 2005 

# data from urban populations only 




rf 
9 



Average cholesterol levels 

in men more than 0.4 mmol/litre 

higher than in women 



Average cholesterol levels 

in women more than 0.4 mmol/litre 

higher than in men 



6.0 and above 
5.5-5.99 
5.0-5.49 
3.0-4.99 

no data 




Fatty deposits along the inside 
of artery walls lead to 
atherosclerosis and 
narrowing of the arteries. 

Trends in cholesterol levels in Beijing, China 

Average total cholesterol in people aged 25 to 64 years 5 25 

7984-7999 

mmol/l 

'1999 




1996 



1996 



1984 



1993 



31 



Risk factor: tobacco 



"From a short pleasure can come a long 

repentance." 

French proverb 



The public may believe that the 
major risk from cigarettes is lung 
cancer, but far more smokers 
develop cardiovascular disease 
mainly heart attacks and stroke. In 
1940, a link was identified 
between cigarette use and 
coronary heart disease, and there 
is now a huge body of scientific 
literature linking tobacco with 
CVD. The risks are much higher 
in people who started smoking 
before the age of 16. Tobacco 
use, other than smoking, and 
passive smoking are also 
implicated as CVD risks. 

Smoking promotes CVD 
through several mechanisms. It 
damages the endothelium lining 
of the blood vessels, increases 
cholesterol plaques (fatty deposits 
in the arteries), increases clotting, 
raises LDL-cholesterol levels and 
lowers HDL, and promotes 
coronary artery spasm . Nicotine 
accelerates the heart rate and 
raises blood pressure. 

A gene has been discovered that 

o 

increases smokers' risk of 
developing coronary heart disease 
by up to four times. Around a 
quarter of the population carries 
one or more copies of this gene. 

Women smokers are at 
particular risk, with a higher risk 
of heart attack than male 
smokers. Women who smoke 
only three to five cigarettes a day 
double their risk of heart attack, 
while men who smoke six to nine 
cigarettes a day double their risk. 



32 



Cardiovascular risks of smoking 



Percentage increase in risk 

100% 
increase in risk 



300% 

increase in risk 




more than 300% 

increase in risk 



400% 

increase in risk 



stroke; coronary 

heart disease; 

impotence 



death from 

undiagnosed 

coronary heart 

disease 



Aim 

'' 



peripheral 
arterial 
disease 



aortic 
aneurysm 



Cardiovascular risks of passive smoking 



Adults 

Harms, clogs, and weakens arteries 
Heart attack, angina, stroke 



Children 

Reduces amount of oxygen the blood can carry 

Damages arteries 

Earlv-onset atherosclerosis 

Sudden infant death svndrome (cot death) 



Smokers don't know the risks of heart attack 



Percentage of smokers 
in the USA 

who believe they have 
higher-than-average 
i/ftThf heart attack -, 
1399 




39% 

heavy Y4 
smokers 
(40 or 

more 
per day) 





ft 



"S, 

1 <2> 

*$* 



'*'. 



DOMINICAN 

~^W~ r ~* 

"'"T VINCENT E, ^ST LUCIA. 

GRENABIS-0 BARBADOS. 
COSTA RICA ,,* 
PANAMA* 




MAURITANIA **Al 
SENEG* 



KIIAIKM 




UWJGUAv 



Men 





Smoking prevalence 

Percentage of people aged 18 years and above 

who smoke 

2003 or latest available data 

* data from urban populations only 

IB 6Qo/o and above 
B 45o/o-59.9% 
300/0-44.9% 



LATVIA 
LITHUANIA 
-BELARUS 
Y POLAND 




JAMAICA "*'" EP 
EMALA STVINCENTE, ^ LUCIA. 

GRENADINES^ O B^BOS, 

COST * RI " VtNBUBA. 




CAMBODIA PHIUPP.NB 



URUd 
AB6ENTINA 




Women 




8 



"Take a stroll after meals and you won't 

have to go to the medicine shop." 

Ancient Chinese proverb 

Industrialization, urbanization and 
mechanized transport have 
reduced physical activity, even in 
developing countries, so that 
currently more than 60% of the 
global population are not 
sufficiently active. 

Physical exercise is linked to 
longevity, independently of 
genetic factors. Physical activity, 
even at an older age. can 

O ' 

significantly reduce the risk of 
coronary heart disease, diabetes, 
high blood pressure, and obesity, 
help reduce stress, anxiety and 
depression, and improve lipid 
profile. It also reduces the risks of 
colon cancer, breast cancer and 
ischaemic stroke. 

Doing more than 1 50 minutes 
of moderate physical activity or 
60 minutes of vigorous physical 
activity a week whether at 
work, in the home, or elsewhere 
can reduce the risk of coronary 
heart disease by approximately 
30%. 

Despite documented evidence 
of the benefit of physical activity 
in preventing and treating 
cardiovascular and other chronic 
diseases, more than a quarter of a 
million individuals die each year 
in the United States because of a 
"lack of regular physical exercise". 

Only 8% of the world's 
population currently owns a car. 
Between 1980 and 1998, the 
global fleet of cars, trucks and 
buses grew by 80%, with a third 
of the increase taking place in 
developing countries. 



34 



Risk factor: 
physical inactivity 



Sitting 

Time spent seated each week, 

people aged 18 years and above 

2000 

selected countries 



j/nours 35 hou| 

U^! S 29 hours 




Finland, Italy Netherlands Spain United 
France Kingdom 



Physical activity 

The following activities have similar benefits to health: 

Washing and waxing a car for 45-60 minutes 

Washing windows or floors for 45-60 minutes 

Playing volleyball for 45 minutes 

Wheeling self in wheelchair for 30-40 minutes 

Bicycling 8 km in 30 minutes 

Pushing a pushchair 2.5 km in 30 minutes 

Walking 3 km in 30 minutes 

Swimming laps for 20 minutes 

Playing basketball for 15-20 minutes 



Physical inactivity by social class in India 

Percentage of time spent seated, at work or in spare time, 
by people aged 25 years and above in two Indian villages 
7993-7995 




82o/o 



69% 




27% 



D 



lowest 



6% 6% 

CDCD 

next lowest next highest highest 



37% 



r 




UNITED 
KINGDOM omuHK 




INLAND 



SWEDEN 



^u. 



JIIH 



GERMANY 



BELGIUM - 

MflVAKiA 
LUXEMBOURG ^^ 

FRANCE ^a 

CROATI 

ITAIY 
SPAIN 
ff^H 
PORTUGAL GREECE 



BRAZIL 




Mf ^ 

URUGUAY MM|^^B|j^HH|^H|^HHjj^^^^^|^^HHHHBMB| 

Physical activity levels 

Energy expenditure per week in work, leisure and transport 

MET-mins 

2002-2003 

1 MET is the amount of energy expended while sitting quietly at rest 

H 6000 and above below 1300 ^ 

HI 3500-5999 no data 




Singapore keeps moving 

Percentage participation in any form of sport for 

at least 20 minutes, on 3 or more days a week, by age 

1998 



750 



^y female 






240/0 


9 male 














16% 








11 O/n 












^^^^ 




1 1 /U 








16% 








32% 




25% 




9%| 








24% 












=s 
14% 




1 6% 












Transport 

Number of motor vehicles 

per 1000 people 

7996 

selected countries 



The global fleet 

Number of vehicles 1000 
1950-1994, million 

2025 projected 

630 

million 



97 



81 



8 




USA Japan Brazil Hong China India 
Konq 



1950 1994 2025 



18-29 30-39 40-49 50-59 60-69 
years years years years years 



35 



"Eat less at dinner and you will live to 

ninety-nine." 

Ancient Chinese proverb 



Belt size, abdominal girth and 

O 

waist-to-hip ratio are useful 
indicators of obesity. The Body 
Mass Index (BMI), a measure of 
weight in relation to height, is 
commonly used for classifying 
overweight and obesity. 

The risks of cardiovascular 
disease and type 2 diabetes tend to 
increase on a continuum with 
increasing BMI, but for practical 
purposes a person with a BMI of 
over 25 is considered overweight, 

o ' 

while someone with a BMI of over 
30 is obese. But one size does not 
fit all. In women, a BMI as low as 
2 1 may be associated with the 
greatest protection from coronary 
heart disease death. The BMI for 
observed risk in different Asian 
populations varies from 22 
to 25 kg/m 2 . 

Availability of food, changes in 
the kind of food eaten, and 
decreased exercise are presenting 
humanity with one of its greatest 
challenges. Low fruit and 
vegetable intake accounts for about 
20% of CVD worldwide. Obese 
smokers live 1 4 fewer years than 
nonsmokers of normal weight. 

More than 60% of adults in the 
USA are overweight or obese. 
Triple-width coffins, capable of 
holding a 300 kg (700 Ib) body, are 
in increasing demand. Worldwide, 
airlines are having to recalculate 

O 

their passenger "payload" weight. 
There are 70 million overweight 
people in China. South Pacific 
populations used to be physically 
active and slim, but the region now 
has some of the world's highest 
rates of obesity. 



Risk factor: obesity 



Food consumption 

Trends in food consumption in 
developing and industrialized countries 
7964- 7999, 2075 projected 
kcal per capita per day 



Industrialized 29 _ 4 Z 
countries 



Developing 2 Q54 
countries 

1964-66 




1974-76 



1984-86 



1997-99 



2015 





"If you and three 

friends together 

weigh more than 

360kg, you get a 

free bottle of 

whisky." 

Ichub Club. 

fat-themed 

karaoke bar in 

Bangkok, 

Thailand, 

2002 



Apple shape at higher risk of CVD than pear shape 

Waist-to-hip ratio of 0.91 and above is associated with nearly 
threefold increased risk of coronary heart disease. 



Increased CVD risk if: Men 



Women 



Waist to hip ratio 
Waist measurement 


more than 0.90 

more than 101cm 
(40 inches) 


more than 0.85 

more than 89cm 
(35 inches) 




Cartoon characters used to promote the 
WeightWise campaign of the British 
Dietetic Association. 




36 








NIGERIA 
GHANA .CAMEROON 



JAfAN 
REP 
KOREA 



COOK 
ISLANDS 

THAILAND 

PHILIPPINES 



N D N E S I A 



Men 

Body 

HiHHH 



MALAWI 
ZIMBABWE 



Mass Index (BMI) 



Average BMI of people aged 1 5 years and above 

estimated to 2005 

kg/m 2 

* data from urban populations only 



18-22.9 
no data 





Women 



10 



"The urine of diabetics is wonderfully 

sweet as if imbued with honey or sugar." 

Thomas Willis (1621-1675), physician to 

King Charles II, England 

Diabetes is a risk factor for 
coronary heart disease and stroke, 
and is the most common cause of 
amputation that is not the result 
of an accident. 

Insulin is a hormone produced 
by the pancreas and used by the 
body to regulate glucose (sugar). 
Diabetes occurs when the body 
does not produce enough insulin, 
or cannot use it properly, leading 
to too much sugar in the blood. 
Symptoms include thirst, 
excessive urination, tiredness, and 
unexplained weight loss. 

There are two main types of 
diabetes. Type 1 diabetes, in 
which the pancreas stops making 
insulin, accounts for 10% to 15% 
of cases. The majority of people 
with diabetes have type 2 disease, 
in which insulin is produced in 
smaller amounts than needed, or 
is not properly effective. This 
form is preventable, because it is 
related to physical inactivity, 
excess calorie intake and obesity. 
People with type 1 diabetes need 
insulin injections to lower blood 
sugar, but many people with 
type 2 do not. 

At least half of all people with 
diabetes are unaware of their 
condition. Diabetes is more 
prevalent in developed countries, 
but modernization and lifestyle 
changes are likely to result in a 
future epidemic of diabetes in 
developing countries. 



Risk factor: diabetes 



CANADA 




Lifestyle changes can be 
more effective than drugs 
in preventing type 2 
diabetes. 



GREENLAND 
(DK) 





DOMINICAN 



JAMAICA 
BELIZE 

GUATEMALA HONDURAS 

EL SALVADOR 



HAITI 

ST Kins Et NEVIS I 



NICARAGUA 
COSTA RICA 



r-. ANTIGUA ft BARBUDA 
O DOMINICA 
ST VINCENT ft GRENADINES O$T LUCIA 

GRENADA 6 O BARBADOS 

^ TRINIDAD Et TOBAGO 
VENEZUELA 



GUYANA 



COLOMBIA 





CAPE VERDE O 

SENEGAL 

GAMBIA 

GUINEA-BISSAU 

GUI 

SIERRA LEONE 




38 



Prevalence of diabetes 



D 

DM 

NETH 
BELGIUM 
I 


LATVIA 
DENMARK LITHUANIA 

BELARUS 
GERMANY " OWN 
"PUBLIC SLOVA K,A "*** 


HI 10%-14.9% 
50/o-9.90/o 



Percentage of people aged 20 and above Top 5 

with diabetes 2000 largest numbers 

^_ of people aged 20 and above 

15% and above below 5% with diabetes 

2000 
no data 



RnMANIA 



. 

AUSTRIA HUNGARY 
FRANCE SWITZ. SIOVENIA BOSNIA ft 

S MARINO HERZEGOVINA 

"CROATIA ' SERBIA & BULGARIA 

-ORRA MONACO ITALY 




RUSSIAN FEDERATION 



KAZAKHSTAN 



TURKEY "\. TURKMENISTAN 

Vlfcj TAJIKISTAN 

"* CYPRUS SYRIAN ARAB 

LEBANON- " EPUBUC ISL REP ' AFGHANISTAN 

ISRAEL- 



LIBYAN 
ARAB 

JAMAHIRIYA 



EGYPT 



CHAD SUDAN 



IRAQ IRAN 



SAUDI ARABIA 



PAKISTAN 




MONGOLIA 



C H I 



BANGLADESH 

MYANMAR 



ERITREA YEMEN 

DJIBOUTI 
ETHIOPIA ^ 



EQUATORIAL CAMEROON 
GUINEA 



GABON 

DEM. REP. RWANDA 

CONGO CONGO BURUNDI 



UNITED REP 
TANZANIA 

COMOROS 

MALAWI 
IBIA 

MADAGASCAR 
ZIMBABWE MAURITIUS 




SOUTH 
AFRICA 



SWAZILAND 
LESOTHl 



Diabetes prevalence and trends 

c 

8.4% 



Percentage of people aged 20 and above 
with diabetes 



2000 2030 

developed countries 




2000 2030 

developing countries 

4444444-4-4 



4 \ + 



39 



11 



"Wealth is both an enemy and a friend." 
Nepalese proverb 



In developing countries, coronary 
heart disease has historically been 
more common in the more 
educated and higher 
socioeconomic groups, but this is 
beginning to change. In industrial 
countries, such as Canada, the 
United Kingdom, and the United 
States, there is a widening social 
class difference in the opposite 
direction. 

Studies in developed countries 
suggest that low income is 
associated with a higher incidence 

o 

of coronary heart disease, and 
with higher mortality after a heart 
attack. The prevalence of risk 
factors for heart disease, such as 
high blood pressure, smoking and 
diabetes, is also higher. The use of 
medications is lower, especially of 
lipid-lowering agents and ACE 
inhibitors, as well as other 
treatments, such as cardiac 
catheterization. 

The pathways by which 
socioeconomic status might affect 
cardiovascular disease include: 
lifestyle and behaviour patterns; 
ease of access to health care; and 
chronic stress. 



Risk factor: 
socioeconomic status 




Prevalence of CVD risk factors 
by education in Canada 

Percentage of people aged 1 8 to 74 years 
with high levels of physical inactivity 
and high cholesterol, by educational level, 
age standardized 1986-1992 





men 

f women 

physical inactivity 

high cholesterol 



secondary school not complete' 
47% 
46% 

secondary school completed 
37% 




45% 




physical inactivity 
high cholesterol 

university degree obtained 
physical inactivity 37% 

high cholesterol 



38% 




The CVD mortality gap in the USA 



Percentage increased CVD mortality 

of lowest socioeconomic (SE) group 

over highest SE group, 

in people aged 25 to 64 years 

7969-7998 

49% 



94% 



79% 



30% 
1969-1970 1997-1998 




Prevalence of high blood pressure 
by income in Trinidad and Tobago 



Percentage of women aged 24 to 85 years with blood pressure 

of 140/90 mmHg or above, or currently treated 

2007 



1% 

III ~ 




less than 
US$134 



US$ 
134-267 



US$ 
268-533 



US$ US$ more than 

534-1067 1068-2133 US$2133 



monthly household income 



I 



Educational level and 
obesity in Italy 



Percentage increased risk of obesity in people 

aged 35 to 74 years, 380% 

in comparison 

with university graduates 

7998 



2200/0 



I 






250% 



upper 
secondary 
education 60% 
diploma 



no 
qualification 





In China, years of education are more important than occupation, income or 
marital status in relation to cardiovascular risk factors, especially cigarette 
smoking. 




Smoking and occupation in Uganda 



Percentage of women aged 1 5 to 54 years and men aged 1 5 to 59 years 

who currently smoke daily by category of work 

2000-2007 



34% 



33% 



29% 



** ^% ^% 



14% 



10/Q 



0% 



3% 



agriculture, unskilled 
self-employed manual 



skilled 
manual 



* Smo 



sales professional, unemployed 
technical, (previous 
managerial, 12 months) 
clerical 



Smoking by years of education in South Africa 



Percentage of people aged 15 years and above who currently smoke daily 
7998 

; f men 
r women 



45o/o 



45o/o 



39% 



35% 



33% 



25o/o 



100/ 



jl 



8% 9% 8% 

no up to 6-7 8-11 12 more than 

education 5 years years years years 12 years 



Income and obesity in Saudi Arabia 

Percentage of people aged 20 years and above 
with Body Mass Index 
of more than 30 kg/m 2 
7990-7993 




income less than US$ US$ more than 

US$533 533-1066 1067-2133 US$2134 




Prevalence of diabetes 
by income in India 



Percentage of people 
aged 20 years and above 
with diabetes, 
by income level 
2000 



22% 




less than 



more than 



US$111 112-223 US$223 



41 



12 



Women: a special case? 



Widespread misconceptions 
persist about heart disease, often 
thought to be primarily a disease 
of middle-aged men. In reality, 
cardiovascular disease affects as 
many women as men, albeit at an 
older age. Many women still 
believe that they are more at risk 
from cancer than from heart 
disease. 

Risk factors for CVD are similar 
for men and women, but tobacco 
use is more dangerous in women. 
In addition, high blood 
triglycerides are an important 
cause of atherosclerosis in young 
women, but not in young men. 
The menopause has no direct 
effect, but hormone replacement 
therapy increases the risk of 
CVD. 

Heart disease is under-detected 
in women, particularly younger 
women. In developed countries, 
women are less likely to be 
referred to a heart specialist, to 
be hospitalized, to be prescribed 
medicine or invasive treatment, 
or to be referred for exercise 
testing or echocardiography. 
Women are more likely to enter 
the medical system with the 
diagnosis of a second heart attack. 

After a first stroke, women are 
kept in hospital longer, and 
remain more disabled than men 
receiving similar care. More 
research is needed to improve our 
understanding of the differences 
in responses to treatment in men 
and women. 

In the interim, however, 
adherence to the published 
guidelines for the prevention and 
control of heart disease and stroke 
seems prudent. 



42 




Risk factors 

Modifiable risks - risk or prevalence is higher in women than men 



Tobacco use (higher risk) 
High triglyceride levels (higher risk) 
Diabetes (more prevalent) 
Obesity (more prevalent) 
Depression (more prevalent) 



Modifiable risks - risk is similar in men and women 

High blood pressure 

High total cholesterol 

Low HDL-cholesterol 

Combined hyperlipidaemia 

Unhealthy diet 

Physical inactivity 

Stress 



Risks for women only 

Oral contraceptive use 

Hormone replacement therapy 

Polycystic ovary syndrome 

Risk of heart attack highest early in each menstrual cycle 



Non-modifiable risks for men and women 

Advancing age 

Gender 

Heredity 

Ethnicity/race 



Smoking 

Percentage increase in risk of heart attack 
in people who smoke in Denmark 
7976-7993 




60% 



ex-smokers light smokers moderate smokers heavy smokers 

(1-Hg/day) (15-24 g/day) (>24g/day) 




Women who smoke are at 

higher risk of heart attack 

than men who smoke. 




No time to walk 

Percentage of women in the United Kingdom 
aged 15 years and above who do not exercise more 
because of lack of time or motivation 
2003 
40% 



Walking re 
coronary heart disease 

Percentage reduction in risk of 
coronary heart disease by non- 
vigorous walking in women 
45 and above in the USA 
7992-7999 






Hormone 
replacement therapy 

Percentage increase 
in risk of CVD 
in healthy women 
using HRT in the USA 
7997-2000 



41% 



111% 



29% 

lul 



no time not motivated 
to exercise to exercise 




1-59 
minutes 
a week 



1-1.5 2 or more 

hours hours 

a week a week 



22% 



coronary 

heart 

disease 



stroke 



deep 

venous 

thrombosis 




43 



PART 3 



THE BURDEN 




"You don't get to choose how you're going to die, or when. 
You can only decide how you're going to live now." 

Joan Baez, folk singer and activist, USA (1941-) 



45 



13 



"Misfortunes always come in by a door 

that has been left open for them." 

Czechoslovakian proverb 



Disability-adjusted life years 
(DALYs) lost can be thought of as 
"healthy years of life lost". They 
indicate the total burden of a 
disease, as opposed to simply the 
resulting deaths. 

Cardiovascular disease is 
responsible for 10% of DALYs 
lost in low- and middle-income 
countries, and 18% in high- 

O 

income countries. 

A heart attack occurs when the 
blood vessels supplying the heart 
muscle become blocked, starving 

O 

it of oxygen, leading to the heart 
muscle's failure or death. Heart 
attack has the same risk factors as 
CVD in general. Cold weather. 

O 

exercise, or strong emotion can 
precipitate a heart attack. 

Coronary heart disease is 
decreasing in many developed 
countries, but is increasing in 
developing and transitional 
countries, partly as a result of 
increasing longevity, 
urbanization, and lifestyle 
changes. 

Risk of heart attack can 
change when people migrate. 
Japan has a low rate of 
coronary heart disease, but 
after moving to the USA, 

O 

Japanese people have been 
found to have a gradually 
increasing risk. This 

O 

eventually approaches that 
of people born in the USA. 



Global burden of coronary 
heart disease 




Coronary heart disease burden is projected to 
rise from around 47 million DALYs globally in 
1990 to 82 million DALYs in 2020. 




USA 



JAMAICA 
BELIZE 
HONDURAS 



REP 



ST KITTS ft NEVIS 0O ANTIGUA ft BARBUDA 



EL SALVADOR 

NICARAGUA 



ST VINCENT ft GRENADINES 



COSTA RICA 

PANAMA 



6RENADA .3 O BARBADOS 

'-' TRINIDAD ft TOBAGO 
VENEZUELA 

GUYANA 



GUINEA-BISSAU 

GUINI 
SIERRA LEC 



46 



sase burden in men 



Percentage of DALYs lost 
due to top ten diseases 
n men aged 15 years and above 
2002 



HIV/AIDS coronary 
7.4% heart disease 
6.8% 



chronic 
obstructive 
pulmonary hearing 
disease loss . 
3.1% adult 
2.7% 



alcohol 

use 
disorders 



tuberculosis 
4.2% 




ElANP 




UNITtD 

KINGDOM 



MNLAND 
SWEDEN 
NORWAY 

ESTONIA 

LATVIA 

LITHUANIA 



DENMARK 



Healthy years of life lost to coronary heart disc 

DALYs lost per 1000 population, age-standardized 
estimates for 2002 

Disability-adjusted life years combine years of potential life lost due 
to premature death with years of productive life lost due to disability 




3 NIGERIA 
||| 

OIRt * 2 CENTRAL AFRICAN 

REPUBLIC 
EQUATORIAL CAMEROON 

GUINEA UGANDA 

GABON KENYA 

^PRINC^E DEM-REP. RWANDA 

CONGO BURUMO, 

UNITED REP 
TANZANIA 



MALAWI 



ANGOLA 

ZAMBIA 

ZIMBABWE 

NAM ' BIA BOTSWANA 

MOZAMBIQUE 



COMOROS 



MAURITIUS 



SOUTH 

AFRICA LESOTHO 



SWAZILAND 



AUSTRALIA 



unipolar 
depressive 
disorders 



HIV/AIDS 
7.2% 





-4-4 



coronary 
heart 
disease stroke 

5.3% 5.2% 



Disease burden in women 

Percentage of DALYs lost due to top ten diseases 
in women aged 15 years and above 
2002 



chronic 
obstructive 
cataracts h " ring pulmonary 

3 ' 1% ->8% d o S C tuberculosis osteo- diabetes 
1.8% 2.7% 26% arthrit . s mdijtus 





47 



14 



"People live with their own idiosyncrasies 

and die of their own illnesses." 

Vietnamese proverb 



Civilization kills. Since 1990, 
more people have died from 
coronary heart disease than from 
any other cause. Unlike stroke, 
coronary heart disease is a 
comparative newcomer on the 
world stage. Variations in death 
rates are marked: they are lower 
in populations with short life 
expectancy. 

Heart disease mortality rates are 
also affected by differences 
between countries in the major 
risk factors, especially blood 
pressure, blood cholesterol, 
smoking, physical activity and 
diet. While genetic factors play a 
part, 80% to 90% of people dying 
from coronary heart disease have 
one or more major risk factors 
that are influenced by lifestyle. 

Death rates from coronary heart 
disease have decreased in North 
America and many western 
European countries. This decline 
has been due to improved 
prevention, diagnosis, and 
treatment, in particular reduced 
cigarette smoking among adults, 
and lower average levels of blood 
pressure and blood cholesterol. It 
is expected that 82% of the future 
increase in coronary heart disease 
mortality will occur in developing 
countries. 

Of all coronary heart disease 
patients who die within 28 days 
after the onset of symptoms, 
about two-thirds die before 
reaching hospital. This highlights 
not only the need for early 
recognition of the warning signs 
of a heart attack, but also the 
need for prevention. 

48 



Deaths from coronary 
heart disease 




Despite implements in survival 

1 in 4 men^Bi 1 in 3 women still die withir 

of a recogn^B first heart attack. 



Deaths from 
coronary heart disease 
compared with other causes 

Number of deaths of people 
aged 15 to 59 years, 
and 60 years and over 
2002 
thousands 




CAPE 

VERDE MAfl 



GUINEA-BISSAUj 
OUINfl 



15-59 years 



60 years and above 



Deaths from coronary heart disease 



Number of deaths from coronary heart disease 
2002 



1000-9999 T P 3 



highest number of 
deaths from 
coronary heart 
disease 



500 000 and above 
100000-499999 
10 000-99 999 




-49% 



increase in death rates 

Croatia 
Kazakhstan 
Belarus 
Ukraine 
Romania 
Japan -10% 

Hungary -2% ||+2% 

-11% -15% Greece 
-19% l^HB^l Portugal 
USA 

Netherlands 
-40% -Mi Sweden 

Luxembourg 
Australia 

Denmark 
decrease in death rates 




Change of heart 

Percentage change in 

coronary heart disease death rates, 

in people aged 35 to 74 years 

7988-7998 

selected countries 

women 
men 



49 



15 



"I waked and sat up.. .when I felt a 

confusion and indistinctness in my head 

which lasted, I suppose about half a 

minute. Soon after I perceived that I had 

suffered a paralytick stroke, and that my 

Speech was taken from me." 

Samuel Johnson, England, 1783 



Stroke is the brain equivalent of a 
heart attack. Blood must flow to 
and through the brain for it to 

o 

function. If its flow is obstructed, 
by a blood clot moving to the 
brain, or by narrowing or bursting 
of blood vessels, the brain loses its 
energy supply, causing damage to 
tissues leading to stroke . 

Annually, 1 5 million people 
worldwide suffer a stroke. Of 
these, 5 million die and another 
5 million are left permanently 
disabled, placing a burden on 
family and community. Stroke is 
uncommon in people under 
40 years; when it does occur, the 
main cause is high blood pressure. 
Stroke also occurs in about 8% of 
children with sickle cell disease. 

The major risk factors for stroke 
are similar to those for coronary 
heart disease, with high blood 
pressure and tobacco use the most 
significant modifiable risks. Atrial 
fibrillation, heart failure and heart 
attack are other important risk 
factors. 

The incidence of stroke is 
declining in many developed 
countries, largely as a result of 
better control of high blood 

o 

pressure, and reduced levels of 
smoking. However, the absolute 

O 

number of strokes continues to 
increase because of the ageing 
population. 



Global burden of stroke 




CANADA 



The increased risk of stroke from taking 
contraceptive pills is substantially reduced by 
using the modern, low-dose pill. 




EL SALVADOR 

NICARAGUA 




COSTA RICA 

PANAMA 



ST VINCENT ft GRENADINES 

GRENADA^ T 
VENEZUELA 



J BARBADOS 
RINIDAD a TOBAGO 



MAURIlB 

CAPE VERDE O fl 

GAMBIA 2| 
GUINEA-BISSAU' 



COLOMBIA 




^ 
UINI 



GUI 
SIERRA LEO 



50 




Healthy years of life lost to strol 



DALYs lost per 1000 population, age-standardized 

2002 

Disability-adjusted life years combine years of potential life lost due 

to premature death with years of productive life lost due to disability 



NETH. 
BELGIUM GERMANY 



IMK.TDIA HUNGARY MOiDOV 

AUSTRIA ROMANIA 

SWITZ. SLOVtNIA BOSNIA ft ^Kff 

HERZEGOVINA 

ChVAtt* I SERBIA h _...-. 
MONTENeSRO BUlGAI1 
ANDORRA' MONACO lwy 




1 "" CH ' " 

I NIGERIA 

I^H CENTRAL AFRICAN 

REPUBLIC ^P^^^pq 

OUATORIAL'V EROON 
GUINEA 

JKBfl NYA 

' : , i as- 





MARSHALL ISLANDS 





1 


KIRIBATI 
NAURU 




9 SAMOA 
TUVALU A 




COOK 


h 

PHILIPPINES 


ISLANDS 
FUI NIUE , 

VANUATU ^ * 




N D N E S I A 

^ ^rTMOR-LESTE 




Stroke in young people 

Number of new cases of stroke 
per 100 000 people per year 
selected populations 
7986-7997 



10 



14 







AUSTRALIA 



26 



/ ? ? f ? / 




NEW 
ZEALAND 



age 17-49 years 15-44 15-44 
Israel Italy Italy 

Florence North 



0-39 40-49 
Kuwait Kuwait 



15-40 20-54 11-50 

Libyan South Africa Spain 
Arab Blacks 

Jamahiriya 

Benghazi 



Cantabria 



20-44 20-44 20-44 

USA USA USA 

Northern Northern Northern 

Manhattan Manhattan Manhattan 

Blacks Hispanics Whites 



51 



16 



Stroke carries a high risk of death. 

O 

Survivors can experience loss of 
vision and /or speech, paralysis, 
and confusion. Historically called 
"apoplexy", "stroke" is so called 
because of the way it strikes 
people down. 

Previous stroke significantly 
increases risk of further episodes. 
Certain racial, ethnic and 
socioeconomic groups are also at 
greater risk of stroke. The most 
important modifiable cause of 
stroke is high blood pressure; for 
every ten people who die of 
stroke, four could have been 
saved if their blood pressure had 
been regulated. Among those 
aged under 65, two-fifths of 
deaths from stroke are linked to 
smoking. Other modifiable risk 
factors include unhealthy diet, 
high salt intake, underlying heart 
disease, diabetes and high blood 
lipids. 

The risk of death depends on the 
type of stroke. Transient 
ischaemic attack or TIA where 
symptoms resolve in less than 
24 hours has the best outcome, 
followed by stroke caused by 
carotid stenosis (narrowing of the 

v o 

artery in the neck that supplies 
blood to the brain). Blockage of 
an artery is more dangerous, with 
rupture of a cerebral blood vessel 
the most dangerous of all. 

Even where advanced 
technology and facilities are 
available, 60% of those who 
suffer a stroke die or become 
dependent. Given these dismal 
statistics and the high cost of 
treatment of stroke, high priority 
should be accorded to preventive 
strategies. 



52 



Deaths from stroke 




Stroke is the second leading cause of death 
above the age of 60 years, and the fifth leadir 
cause in people aged 15 to 59 years old. 



... 



% 



DOMINICAN 

JAM *'^ Hafliir 




'.> 



GUATEI 

EL SALVADOR^- 



ST KITTS ft NEVIS C 



, ANTIGUA Et BARBUDA 



:NADAO O BARBADOS 

* TRINIDAD it TOBAGO 




MAURI 

CAPE VERDE e . 

GAMB 
GUINEA-BISSA 



SENM 



GUINl 
SIERRA LEO 



420% 



Predictors of death 
from stroke in Italy 

Percentage increased risk of death from stroke 

in people aged 65 years and above 

2007 



140% 



84% 



83% 



60% 



38% 




previous atrial high impaired cigarette coronary 
stroke fibrillation blood glucose smoking heart 
pressure tolerance disease 

(systolic 
>163 mmHg) 



Number of deaths from stroke 
2002 



Top 3 

highest number of 
deaths from stroke 



200 000 and above 
100000-199999 
10 000-99 999 



1000-9999 
below 1000 
no data 



100/0 

stroke 

5.5 million 



27% 

other causes 
15.6 million 



heart disea 
7.2 milli 



Total 

deaths 

57 million 



12% 
cancer 
1 million 



respiratory 
infections 
3.7 million 
5% 

HIV/AIDS 
2.8 million 




Stroke compared 

with other causes of death 

Percentages and numbers of deaths 
worldwide from stroke and 
other leading causes 
2002 

malaria 
1.2 million 

3% 

tuberculosis 
1.6 million 

30/0 

diarrhoeal diseases 
1.8 million 

40/0 

perinatal causes 
2.5 million 



5% 

chronic obstructive 

pulmonary disease 

2.7 million 



53 



17 



Economic costs 



"The art of economics consists in looking 

not merely at the immediate but at the 

longer effects of any act or policy; it 

consists in tracing the consequences of 

that policy not merely for one group but 

for all groups." 

Henry Hazlitt, USA (1894-1993) 

The costs of cardiovascular disease 
are diverse: the cost to the 
individual and to the family of 
heath care and time off work; the 
cost to government of health care; 
and the cost to the country of lost 
productivity. 

We attempt here to quantify 
some of these costs. However, 
the value of a human life is 
beyond our analysis. 




Global costs of smoking 



Health care costs associated with 
smoking-related illnesses result 
in a global net loss of US$200 
billion per year, with one third of 
those losses occurring in 
developing countries. 
Estimated 1994. 



USA, Australia and Europe 



2002 reports indicate that up to 
10% of health budgets are spent 
on diabetes-related illnesses. 



USA 



Latin America and the Caribbean 



Permanent disabilities resulting 
from diabetes cost US$50 billion 
in 2000, while costs associated 
with insulin, hospitalization, 
consultations and care totalled 
US$10.6 billion. 



uiooai COSTS or uiaoeies 

Between 4% and 5% of health 
budgets are spent on diabetes- 
related illnesses. 
WHO, 2003 



Price of weekly dose of medication 

Expressed in kg of cheapest crop available (yam, rice or potato) 

2003 

selected countries 

Mk "*' -"'' 

Simvastatin 63.0 

^P Aspirin 

50.6 



50.6 



38.4 



33.6 





/ "If just 10% of adults began walking 
regularly, Americans could save US$5.6 
billion in costs related to heart disease." 
- President George W. Bush, 2002. 

The direct costs of physical inactivity 
accounted for an estimated US$24 billion 
in health care costs in 1995. 

I Health problems related to obesity, such 
as heart disease and type 2 diabetes, 
cost the USA an estimated 
US$177 billion a year. 

Cholesterol reducers were the top-sellinc 
medications in 2003, generating 
US$13.9 billion in sales. 

The American Heart Association 
estimates that stroke will cost a total of 
US$53.6 billion in 2004. Direct costs for 
medical care and therapy will average 
US$33 billion and indirect costs from 
lost productivity will be US$20.6 billion. 

In 2001, the National Stroke Association 
estimated that the average cost per 
patient for the first 90 days after a 
stroke was US$15 000, although 10% of 
cases cost more than US$35 000. 






30.0 



25.7 



0.9 



Chile 




1.5 



4.0 



1.4 



13.9 



1.2 



0.5 



4.2 



0.2 



1.6 



China Egypt Georgia Ghana Indonesia Pakistan Sri Lanka Turkey 




54 



United Kingdom 



stroke 



"The direct cost of obesity to the National Health 
Service is 0.5 billion [about US$0.9 billion] per 
year, while the indirect cost to the UK economy is 
at least 2 billion [about US$3.5 billion]." 
- Liam Donaldson, Chief Medical Officer, 2003 

More than 4% of National Health Service 
spending was on stroke services in 2000. 



The economics of CVD 

fctto physical exercise 

B obesity ^ CVD 

cholesterol ^^* tobacco 




Global costs of heart disease medication 




The average total costs of care per patient 
for six months following a stroke were 
estimated at 16 000 in 2003. 

Stroke was estimated to be responsible for 
3% of total health care costs in the 
Netherlands in 1994, and 7% of costs for the 
population aged 75 and over. Stroke ranked 
second on the list of most costly diseases for 
the elderly, after dementia, and these costs 
are expected to increase by 40% by 2015. 




The number of people who die or are disabled 
by coronary heart disease and stroke could be 
halved with wider use of a combination of 
drugs that costs just US$1 4 a year. 
WHO, 2002 




>mgapore 

/Average hospital costs for stroke were 
reported in 2000 as US$5000 per 
patient. Ward charges accounted for 
38%, radiology 15%, doctors' fees 
10%, medications 8%, therapy 7%. 



The cost of risk factors 

Cumulative Medicare costs of treatment of cardiovascular 
disease in people aged 65 years to death, in the USA 

Risk factors: US$38044 US$38059 

US$ high blood pressure, 

high cholesterol, 
cigarette smoking, 
US$18604 abnormal 

electrocardiograms, 

a history of 

diabetes or 

previous heart attacks 



Lifetime costs of coronary heart disc 




US$11 711 




men women 

low risk 
no heart disease risk factors 



men women 

3 or more 
risk factors 



Germany 

7996 

US$ 



Total direct costs 

Including: 
primary care, 
clinical care, 
rehabilitation 



US$48 
billion 




US$26 
billion 



Expenditure on cardiovascular medications 

Percentage of total annual drug expenditure 

7989-7997 

OECD countries 





Total indirect costs 

Lost productivity 
caused by: 
short-term and 
long-term disability, 
death 



Average cost per case: US$82 000 




55 







- 




56 




PART 4 




"Keeping your body healthy is an expression of gratitude to the 
whole cosmos, the trees, the clouds, everything." 

Most Venerable Thich Nhat Hanh, Vietnamese Buddhist monk (1926) 

57 



18 



Research 



"Science knows no country, because 

knowledge belongs to humanity, and is the 

torch that illuminates the world." 

Louis Pasteur, France (1822-1892) 



From the description of how a 
heart muscle cell contracts to the 
elucidation of the human genome, 

o 

scientific advances in basic, 
clinical, and population research 
in cardiovascular disease, and 
their global impact, have been 
phenomenal. New and improved 
treatments have become possible, 
and novel markers of future risk 
have been identified. 

Yet several key challenges 
remain. There is a widespread 
lack of research capacity, 
standardized data, communication 
networks, and human and 
financial resources, especially in 
developing countries. 

The MONICA (Multinational 
MONItoring of trends and 
determinants in CArdiovascular 
disease) Project involved teams 
from 38 populations in 
2 1 countries from the mid- 1 980s 
to the mid-1990s, the largest such 
collaboration ever undertaken. It 
was set up to explain the diverse 
trends in cardiovascular disease 
mortality observed from the 
1970s onwards. The project 
monitored a study population of 
10 million men and women, aged 
25 to 64 years. 

MONICA was important in 
measuring levels and trends in 
cardiovascular diseases and their 
risk factors in different 
populations, in monitoring 
prevention policies in different 
countries, and in demonstrating 
the importance of the new acute 
and long-term treatments that 
were being introduced. 

58 




Regional research 

Percentage of publications on 

CVD by region 
countries jndexed in Med | ine 
not assigned 



developing 
countries _ 

^m 

Eastern 
Europe 



BARBADOS 



TRINIDAD 
h TOBAGO 




2007 



.** 



Clinical trials 

Number of published clinical trials on 
humans in any language in the National 
Library of Medicine's PubMed 
2004 

1 83 Road traffic accidents 



6539 


HIV/AIDS 
Arthritis 
Stroke 




6687 
i 


6912 




9758 


Diabetes 






22468 







ped market 
onomies SENJ 

f GAMBIA 8 

78% 



Pulmonary diseases 



Cancer 
Coronary heart disease 




CVD research publications 

^^i 

Number of publications on cardiovascular disease indexed in Medline 
7997-2007 



Top three countries 



Research funding by the National 



r* 

Institute of Health in the USA 

Spending on disease research 

on/r: 






1 


Emerging 








^Stroke^^^ 
$330m 


Mental 
health 

$1762m 


Biodefense 
$1554m 


infectious I 
diseases 

$1362m 


Drug abuse 
$1023m 


Nutrition 
$1016m 


Diabetes 
$9 10m 



59 



19 



Organizations 



"Don't agonize. Organize." 

Florynce Kennedy, Lawyer, and Civil and 

Womens' Rights Activist (1916-2000) 

The World Health Organization's 
Cardiovascular Disease 
Programme is conducted through 
its Geneva headquarters, and 
regional and national offices 
worldwide. The World Heart 
Federation helps people achieve a 
longer, better life through 
prevention and control of heart 
disease and stroke, focusing on 
low- and middle-income countries. 

In addition to the 
nongovernmental organizations 
(NGOs) highlighted here, there 
are many international NGOs - 
from the World Medical 
Association to Consumers 
International that include 
cardiovascular disease control as 
part of their activities. 

Only international and regional 
organizations are shown here. 
Not mentioned are the many 
national organizations, whose 
impact may extend outside their 
own country, such as the Centers 
for Disease Control and 
Prevention in the USA, the 
British Heart Foundation, and 
ThaiHealth in Thailand. Other 
national NGOs also work part 
time on CVD issues. 

There are numerous other 
partners in a vast arena of varied 
but related interests, including 
organizations involved with 
women, youth, law, economics, 
human rights, religion and 
development. 

The capacity of virtually all 
cardiovascular disease control 
organizations is inadequate to 
meet the challenge of the CVD 
epidemic. 

60 




World Health Organization 
headquarters, Geneva 







Mexico 



InterAmerican 
Society of Cardiology 



USA 



WHO RO Americas/Pan American Health Organizatic 

CardioStart International Inc. 

Cardiothoracic Surgery Network 

Children's HeartLink 

Congenital Heart Information Network 

Gift of Life International Inc. 

HeartGift Foundation 

Heart-to-Heart International 

Heart-to-Heart Int. Children's Medical Alliance 

International Children's Heart Foundation 

International Children's Heart Fund 

International Hospital for Children (IHC) 

International Stroke Society 

Loma Linda University Overseas Heart Surgery Team 

Save A Child's Heart Foundation 

World Heart Foundation 

Heart of the Americas 

InterAmerican Heart Foundation 



World Conferences on Cardiovascular 



World Congresses of Cardiology 



1 st 1974 Buenos Aires, Argentina 

2" (l 1978 Tokvo, japan 

V' (1 1982 MOM <m , Russian Federation 

4 th 1986 Washington, DC, USA 

5'' 1 1990 Manila, Philippines 

6 th 19^4 Berlin, (ii-i-mam 

7 th 1998 Rio do Janeiro, Brazil 

8 th 2002 Svdnov, Australia 

l " 1 ' 2006 Barcelona, Spain 




International Conferences on 
Preventive Cardiology 

lt 1985 Mosom, USSR 

2nd 1989 Washington, DC, USA 

3"! 1993 Oslo, Nor\\a\ 

4 th 1997 Montreal, Canada 

5 th 2001 Osaka, Japan 

6 th 2005 Iguassu, Bra/il 



United Kingdom 



World Federation of Neurology 
European Heart Institute 



Belgium 



European Heart Network 



CVD organizations 

WHO, Headquarters (HQ) and regional offices (RO) 
International CVD organizations 
Regional CVD organizations 










Denmark 


Austria 


WHO RO Europe 




Furnnpan A<;;nriatinn for 





Switzerland 



WHOHQ 

Coeurs pour Tous (Hearts for All) 

World Heart Federation 




ranee 



European Society 
)f Cardiology 



Egypt 



WHO RO Eastern Med. 



Nigeria 



African Heart Network 



Congo 



WHO RO Africa 



China 



International Chinese 
Heart Health Network 



Pakistan 



Asia Pacific Society 
of Cardiology 



India 



WHO RO South-East Asia 
Initiative for Cardiovascular 
Health Research 
in Developing Countries 



Philippines 



WHO RO Western Pacific 
Asian Pacific Heart Network 



'an African Society 
)f Cardiology 




World Stroke Congresses 



!>' 1989 ' Kyoto, Japan 

2nd 1992 Washington, IK , USA 

3 ri1 1996 Munich, Germany 

4 th 2000 Melbourne, Australia 

5 th 2004 Vancouver, Canada 



International Heart Health 
Conferences 



2 n(l 

3 r(l 

4 th 

th 



1995 
1998 

2001 
2004 



Victoria, British Columbia, Canada 

Barcelona, Spain 
Singapore 
Osaka, Japan 
Milan, Italv 



61 



20 



"No matter how far you have gone 

on the wrong road, turn back." 

Turkish proverb 

Good control of blood pressure, 
blood cholesterol and blood sugar 
levels, and other cardiovascular 
risk factors is the key to reducing 
risks of heart disease and stroke. 

Personal behaviour and lifestyle 
choices can make a big difference 
to the risk of coronary heart 
disease and stroke. It is estimated 
that having a high-risk lifestyle 
may account for 82% of coronary 
events in women. Here, we 
identify personal choices that can 
lower individual risk for heart 
disease and stroke. The choices 
apply to young people and adults 
alike. 



Prevention: personal choices 
and actions 



Personal choices in lifestyles and behaviour 

1 Take moderate physical activity for a total 
of 30 minutes on most days of the week. 

2 Avoid tobacco use and exposure to 
environmental smoke; make plans to quit if 
you already smoke. 

3 Choose a diet rich in fruits, vegetables and 
potassium, and avoid saturated fats and 
calorie-dense meals. 

4 Maintain a normal body weight; if you 
are overweight, lose weight by 
increasing physical activity and 
reducing calorie intake. 

5 Reduce stress at home and at work. 




Personal actions for safeguarding cardiovascular health Young people 



1 Discuss all questions with your health care provider. 

2 Have regular check-ups from your health care provider. 

3 Have your blood pressure and levels of blood sugar and 
cholesterol checked. -^ 

4 Follow your health care provider's 
instructions regarding physical 
activity, nutrition, weight 
management, and any medications 
you have been prescribed. 

5 Know the signs and symptoms 
of heart attack and stroke and 
remember that both conditions 
are medical emergencies. 

6 Know your blood pressure and 
cholesterol level, and keep them 
at the recommended levels 
through lifestyle changes and 
by taking any prescribed 
medication. 

7 Lower your total fat and 
saturated fat intake in 
accordance with your health 
care provider's instructions. 

62 




1 Actions and choices for children and 
adolescents with cardiovascular disease, or 
risk factors, should be discussed with a 
paediatrician or health care provider. 

Choose a diet containing a variety of fruits, 
vegetables, whole grains, dairy products, fish 
legumes, poultry, and lean meat. 

There is no need to restrict fat intake in 
children under two years of age. 

4 For children over 
two years and 
adolescents, 
limit foods high 
in saturated fats 
(to less than 
10% of daily 
calorie intake), 
cholesterol (to less 
than 300 mg per 
day), and 
trans-fatty acids. 

Increase physical activity, and 
avoid tobacco use or exposure to 
environmental tobacco smoke. 




Eat fruit and cereals 

Percentage reduction in risk 

with each daily increment of 10 g of dietary fibre 

reported 2004 

all coronary events 
^P coronary deaths _ 7(y 



in tzke 



30% 



14% 



Fibre intake 




25% 



10% 




16% 




total dietary fibre 



cereal 



fruit 




The benefits of stopping smoking 

Time since last cigarette Effect 

20 minutes 

1 day 

3 months 

1 year 

5 to 1 5 years later 

1 5 years later 



Blood pressure and pulse rate drop to normal. 

Probability of heart attack begins to decrease. 

Circulation improves. 

Excess risk of coronary heart disease is half that of a continuing smoker. 

Risk of stroke is reduced to that of people who have never smoked. 



Risk of coronary heart disease is similar to that of people who have 
never smoked, and the overall risk of death almost the same, especially 
if the smoker quits before illness develops. 



63 



21 



"Thinking well is wise; planning well, 

wiser; doing well wisest and best of all." 

Old Iranian proverb 



Significant health gains in 
cardiovascular health can be made 
within short time spans, through 
public health and treatment 
interventions that have an impact 
on large segments of the 
population. 

As shown here, there is a gap 
between what is known and what 
is done in practice, for both 
prevention and treatment of 
cardiovascular disease. 

Governments are stewards of 
health resources, and have a 
fundamental responsibility to 
protect the health of citizens. 
Ministries of Health and the 
health profession can play various 
roles in reducing CVD, by 
making data available, educating 
the public, making treatments 
affordable and available, advising 
patients on healthy living 
practices, and advocating for 
policy and environmental change. 
These have been the essential 
messages of the International 
Heart Health Conferences and the 
related declarations on heart 
health. 




UK dieticians promote the benefits 
for heart health of eating oily fish, 
more fruit and vegetables, and less 
saturated fat. 

64 



Prevention: population 
and systems approaches 

Noncommunicable disease (NCD) prevention and control 

Percentage of countries with integration of components 

of NCD prevention and control programmes in primary health care 

2007 

WHO regions 940/Q 

88% 880/0 



65% 




Africa 



Americas Eastern 



Minca Americas tasicrn Europe South-East Western 

Mediterranean Asia Pacific 



EASTERN 

MEDITERRANEAN WESTERN 

PACIFIC 




Availability of equipment 

Percentage availability of basic equipment 
at primary health care level for diagnosis and 
management of high blood pressure and diabetes 

2001 96% 

WHO regions 

86% 
81% 



for high blood pressure 
for diabetes 



97% 



94% 



96% 



n 




Africa 



Americas Eastern 

Mediterranean 



Europe 



South-East 
Asia 



Western 
Pacific 



Bh 

Medical professionals 

Number of medical professionals working in 

noncommunicable disease control 

per 100 000 population 

2007 

WHO regions 



685 



cardiologists 

primary health care physicians 

nurses 



56 



247 



0.4 
13 



I 




0.3 




Africa 



Americas Eastern 

Mediterranean 



Europe 



South-East 
Asia 



Western 
Pacific 



Antihypertensive drugs 

Percentage of countries in each re 
are available, affordable to low in 
or manufactured locally 
2007 
WHO regions 


gion where drugs 
:ome groups, 










r 30% 1 
890^ 


57% 
91o/o 


67% 


480/o 








45% 


9 locally 
manufactured 

9 affordable 


70/0 

p==5 




740/o 




640/o 








83% 






^7 available 


460/o 




88% 




920/o 




100% 








960/o 




70o/o 






M 








( 


71o/o 




I 

Western 
Pacific 


Africa 


Americas 


Eastern 
;diterranean 


Europe 


>outh-East 
Asia 



Use of medication 
in stroke and 
coronary heart disease 

Percentage prescription of 

aspirin and statins 

to persons with established 

coronary heart disease 

and post-stroke in the WHO 

PREMISE demonstration 

project 

2002 

selected countries 

^ aspirin 
statins 



95% 



96% 



83% 



66% 



29% 



S 



90/0 



790/o 81o/o 



38% 



i 



31% 



28% 



i 



16% 



Brazil Egypt India Indonesia Iran, Pakistan Sri Turkey Russian Tunisia 

Islamic Lanka Federation 

Republic of 



. 




89% 



78% 



660/0 



38% 



j 



23% 



i 



78o/o 



28% 



I 



58% 



22 



Health education 



"Education is the most powerful weapon 

which you can use to change the world." 

Nelson Mandela, South Africa (191 8-) 

For successful prevention and 
control of the cardiovascular 
disease epidemic, changes to 
policy, legislation and taxation are 
not enough. These interventions 
will not be effective if there is no 
public understanding, support 
and demand for them. Some areas 
lie beyond legislation for 
example, the choice of food for 
families, the amount of salt added 
in cooking, whether or not to 
smoke and here health 
education is essential to promote 
healthy choices. 

Schools provide an ideal venue 
for health education. They can 
teach about risk factors, refusal 
skills, and the strategies of the 
tobacco and food industries. For 
example, young people can 
analyse how tobacco industry 
promotion attempts to 
manipulate them by equating 
smoking with growing up, 
freedom and being cool. 

Increasing knowledge, and 

O O ' 

changing beliefs, attitudes and 
intentions, on their own are not 
enough to change behaviour. 
School programmes must also 
lead by example, by making 
healthy food available, providing 
exercise facilities, prohibiting 
tobacco use at all school facilities 
and events, and helping students 
and staff lose weight and quit 
smoking. Ideally, these activities 
should be part of a coordinated 
school health programme, 
reinforced by community-wide 
efforts. 

The WHO Global School 
Health Initiative is designed to 
strengthen international, national 

66 



World Heart Federation event 



participating countries 
and territories 2003 



The Victoria Declaration 
on Heart Health 



Heart Health Declarations 



See Milestones pp76-81 
for further details 



The Victoria Declaration 
on Women, Heart 
Disease and Stroke 




and local support for effective 
school health programmes or 
"health-promoting schools". 
Guidelines have been developed 
on various factors that affect 
health, such as tobacco, diet and 
physical activity. 

The WHO Global School-based 
Student Health Survey is aimed at 
adolescents aged 13 to 15 years, 
and covers nine risk or protective 
factors. Survey results will 
provide information on trends 
over time, which is useful for 
formulation of risk reduction 
policies. 

World Heart Day Themes 

2000 Physical Activity 

2001 A Heart for Life 

2002 Nutrition and Physical 
Activity 




World Heart Day Activities 200? 

medical activities 
(e.g. blood pressure ] 
testing) 





2003 Women, Heart 
Disease and Stroke 

2004 Children, 
Adolescents and 
Heart Disease 

2005 Obesity / 




activities to 
engage the public in 

physical activity I f 



scientific activities 

(e.g. conferences 

or workshops) 



activities 
to advocate for a 
heart healthy diet 

other activities 

(e.g. charity 

gala, dance, 

concert, carnival) 





The Catalonia Declaration 
Investing in Heart Health 



The Osaka Declaration: Health, 
Economics and Political Action 
Stemming the Global Tide 
of Cardiovascular Disease 



The Milan Declaration: 
Positioning Technology to 
Serve Global Heart Health 



998 Singapore 



The Singapore Declaration: 
Forging the Will for Heart 
Health in the Next Millennium 




valuation of World Heart Days 2000-2003 
Number of participating countries and territories 



till 

2000 2001 2002 2003 



Giving up smoking: International Quit and Win 

1994-2002, 2004 projected 

Up to 25% of participants in the International 

Quit and Win Campaign are off tobacco after one year 



1 000000 



Number of participants 



Number of 

website hits more than 
2 000 000 




200 000 




60 000 70000 




420 000 



2000 



2002 



1998 




1994 



1996 



2000 



2001 



2002 



2003 




Number of countries 48 



1998 



67 



23 



Policies and legislation 



"The welfare of the people 

is the ultimate law." 

So/us Populi Supreme Est Lex. 

Cicero (1 06 BCE-43 BCE) 



Laws, treaties, policies and 
regulations have played important 
roles in the prevention and 
control of disease. Only 
governments can legislate for 
health warnings on cigarettes, 
introduce mandatory food 
standards and labelling, crack 
down on smuggling, set a "pro- 
health tax policy", or implement 
national transport policy. Often 
governments are the main 
providers of health care; they 
decide how funding is allocated, 
from prevention programmes to 
treatment, research, and training. 

The first international 
convention that relates specifically 
to cardiovascular disease is the 
WHO Framework Convention on 
Tobacco Control. It was adopted 
without dissent by the World 
Health Assembly in Geneva in 
May 2003, and is currently in the 
process of ratification. Once 
40 countries have ratified the 
Convention, it will come into 
effect as a legally binding treaty 
among those countries. The 

O 

Convention includes clauses on 
advertising bans, smoke-free 
areas, health warnings, taxation, 
smoking cessation and smuggling. 





Cardiovascular disease plans 
worldwide 

Percentage of countries by region 

with national plans for CVD prevention and control 

2007 

WHO regions 

Africa 8% 



Americas 
Eastern Mediterranean 



South-East Asia 
Western Pacific 




50/o 



4QQ/0 



Smoke-free workplaces 

Smoke-free areas in government buildings 

2004 or latest available data 

r ^ Smoking in private workplaces banned. 

Exceptions or limited restrictions may 

smoking banned 
apply to restaurants, bars, 

and other venues. 



First five countries to ratify 
the Framework Convention on 
Tobacco Control. 



smoking restricted 
not regulated 
unknown 



1970 Singapore: smoking banned in buses, 
cinemas, theatres and other specified 
buildings. 




Legislation 

Percentage of countries by region 

with tobacco, and food and nutrition legislation 

2007 

WHO regions 



^ tobacco 
? food and nutrition 



Africa Americas Eastern Europe South-East Western 

Mediterranean Asia Pacific 



69 



24 



Treatment 



"If you do not repair your gutter, you will 

have your whole house to repair." 

Old Spanish proverb 

In 1931, Paul Dudley White 
noted that there was no specific 
treatment for coronary heart 
disease. He described the 
treatment of high blood pressure 
as "difficult and almost hopeless". 
Today, effective and relatively 
inexpensive medication is 
available to treat nearly all 
cardiovascular diseases, including 
high blood pressure. 

Improvements in surgical 
techniques have led to safer 
operations. Effective devices have 
been developed, such as 
pacemakers, prosthetic valves, 
and patches for closing holes in 
the heart. Other developments 
have led to a wide array of 
interventions that often make 



surgerv unnecessar 



7- 
Together, these advances in 

o 

treatment improve quality of life 
and reduce premature death and 
disability. They also add to the 
rising costs of health care. 
Increasingly, high-technology 
procedures are chosen over less 
expensive, but nevertheless 
effective, strategies. 

In addition, marked disparities 
in the quality of treatment can be 
seen in groups of different race, 
ethnicity, sex, and socioeconomic 
status. In essence, many patients 
who could benefit from treatment 
remain untreated, or inadequately 
treated. In future, increased 
emphasis needs to be placed on 
the appropriate use of proven 
treatments for everyone with 
coronary heart disease or stroke. 



70 



Cardiac rehabilitation 

Percentage of people with established 

coronary heart disease advised 

to participate in cardiac rehabilitation 

2007 

selected European countries 




71% 



Patients reaching blood pressure and 
blood cholesterol goals during treatment 

Percentage of people aged 70 years or below with established CVD who achieve blood pressure 

goal of less than 140/90 mmHg, or blood cholesterol goal of less than 5.0 mmol/l 

2007 

selected European countries 

^ blood cholesterol goal achieved 



46% 
50% 



23% 



55% 




63<>/o 




Types of treatment 

Selected medication, devices and operations 

Medication used in treatment of 

1 High blood pressure 

2 Coronary heart disease 

3 Heart failure 

4 Arrhythmia (heart rhythm disorders) 

5 Blood clotting disorders 
Devices 

1 Pacemakers 

2 Implantable defibrillators 

3 Coronary stents 

4 Prosthetic valves 

5 Artificial heart 
Operations 

1 Coronary artery bypass 

2 Balloon angioplasty 

3 Valve repair and replacement 

4 Heart transplantation 

5 Artificial heart operations 

Trends in cardiovascular operations and 
in the USA 

Number of operations and procedures 

7987-2007 

thousands 

* heart catheterization 
^ open heart surgery 

' coronary artery bypass surgery 
f carotid endarterectomy 

* cardiac pacemakers 



ACE 

inhibitors 



aspirin 



Simple secondary 
25% prevention 

medication treatments 

Percentage reduction in 
250/0 two-year risk of heart attack, 
stroke or death from CVD 
in patients with previous 
coronary heart disease 
or stroke 
2002 



card 







Diabetes treatment 

Percentage of persons with diabetes 

being treated with medication or special diet 

2002-2003 

selected countries 




1981 



1986 



1991 



1996 



2001 



71 



* 

s 







PART 5 




THE FUTURE AND THE PAST 



"Let my heart be wise, 
It is the gods' best gift." 

Euripides Medea, 431 BCE 



73 



25 



The future 



"I never think of the future - it comes 

soon enough." 

Albert Einstein (1879-1 955) 

I Inlike I instein, \\e have ID iliink 
ol the lui m . . HI- |)l.in n. P\\ , to 
reduce (In- numbers ol deaths 
I'roin coronary heart disease .mil 
stroke. 

Predictions arc by dicir nature 
.speculative. Nevertheless, tliis 
nun li is certain: the gloh.il 
epidemic of cardiovascular disi-asc 
is nol only increasing, hut also 
shifting from developed to 
developing nations. 

Action can work. There are 
MMI mily ahout 800 million 
people 1 with high hlood pressure 
worldwide. Studies now indicate 
that in North America, Western 
Kurope, and the Asia Pacific 
region, each 10 mmllg lowering 
ol systolic hlood pressin . [| 
assoi iated with a decrease in risk 
ol stroke ol approximately one 
third, in people aged (>() to 7 C ) 
years. (Jobally, if diastolie blood 
pressure (l)UI') can he redu. i d h\ 
2%, and by 7% in those with DBP 
over- l )S mmllg, a million deaths a 

yi .n li HI. n \ heart disease 

and stroke could he averted hy 
2020 in Asia alone. 

No matter what advances there 
are in high technology 
medicine, the rundameiit.il 
message is that am major 
reduction in deaths and 
disability I'rom ('VI ) will 
i Mini liom prevention, 
not i ure. This must 
involve robust reduction 
of risk (actors. 




"Unless current trends are halted or reversed, 
over a billion people will die from 
cardiovascular disease in the first half of the 
21st century. The large majority will be in 
developing countries and much of the life years 
will be lost in middle age. This would be an 
enormous tragedy, given that research in the 
last half of the 20th century showed that 
cardiovascular disease was largely preventable." 

Anthony Rodgers, Clinical Trials Research Unit, 
University of Auckland, New Zealand, 2004 



DALYs 


DALYs 


by 2010 


Disability-adjusted 
life years combine 

yi-ur, nl piilfiilinl 

life lost due to 


CVD DALYs 

Annual number 
of DALYs 


153 million 


premature death 




w 


with years of 




V 


productive life lost 


Burden of CVD 




due to disability. 


Percentage 


10.4% 




of all DALYs 


m* 



by 2020 



169 million 



11.( 



by 2030 
187 million 



11.6% 




CVD 

rankings 
globally 

CVD rankings 

in developing 

countries 



DEATHS 

CVD deaths 

Annual number of deaths 



CVD deaths 

Percentage 
of all deaths 

Coronary heart 
disease deaths 

Percentage of 
all male deaths 

Coronary heart 
disease deaths 

Percentage of 
all female deaths 

Stroke deaths 

Percentage of 
all male deaths 

Stroke deaths 
Percentage of 
all female deaths 

CVD deaths 
from cigarette 
smoking 

Annual number of deaths 



3rd: coronary 

he.irl disease 
Mh stroke 

4th rtirnti.iry 

heart disease 
8th: stroke 



3rd: coronary 3rd: coronary 

hi-,-iri diMMM' heart disease 

4th: stroke 4th: stroke 

3rd: coronary 3rd: coronary 

hr;iti disease heart disease 

6th: stroke 5th: stroke 



by 2010 by 2020 by 2030 

24.2 million 



18.1 million 



30.8% 



13.1% 



13.6% 



9.2% 



20.5 million 



31.50/0 



1 4.3% 



1 3.0% 



9.8% 



11. !% 11.5% 





3 2. !>% 



14.9% 



13.1% 
10.4% 

11.8% 



2.6 million 



l-'l m m 



74 



RISK 
FACTORS 


by 2010 by 2020 


by 2030 


THfATMiNT 1,, 


by 2020 by 2030 


Smokers 


1.4-1. 6 billion 
1.3-1.4 billion 


1.4-1.8 billion 


Miscellaneous lull |irr.nrul 

meili< .il 


Health systems driven Patients' 
by primary health care knowledge of their 


Number 


AA - * *^Bw* 




records 


to ensure universal own health equals 




V 




stored on 


access to quality that of doctors in 








MM. Ill 1 .11(1 


health care services, the 1990s. 


Diabetes 




366 million 






Number of 


300 million 






Irr.l.mtancOUl 


people aged 
20 years 


221 million 






computer language 

iMM-.l.ltlllfl rtl.llill", 


and above 


^P 






ii.iiimi-, in he- 










understood by doctors 


Miscellaneous 


Serious increases 


Short-term, long- 




in any country. 




in LDL-cholesterol 


term, and lifetime 








in many 


absolute risk of 


Investigation ECOs, X-rays, 


Minuscule computer, "Trial and error" In 




developing 


coronary heart 


ultrasound 


with microsensors, drug prescription 




populations. 


disease and stroke 


Images, etc. 


automatically sensing abandoned In 






routinely 


Ir.msmittnl 


and recording health favour of 






calculated by 


electronically 


d.it.i, (i)iil(l hr rvrryil.iy |iOMin.ili/ril 






health care 


t()lll.l(|MI>Ml< 


wear. prescription 






providers for 




through 






everyone. 


in another 


Biochemical pharmacogenomlc 








country. 


inflammation and testing for 










genetic markers used predictable 








Wireless ECGs. 


routinely in blood tests responses to drugs. 










to screen patients for 


ECONOMIC 
COSTS 


by 20 10 by 2020 


by 2030 




heart problems. 


Obesity-related 




'"*' 






complications 
Percentage of 


70% 




Genetics CVD- 
modifying 


Genetic manipulation 
to prevent and treat 


health care 
spending in the 
USA, people aged 


15% 
W 




gcna 

identified. 


CVD, including post- 
operative prevention of 
re-stenosis of arteries. 


50 to 69 years 


W 









ACTION by 2010 by 2020 by 2030 

Research New causal All newborn babies Bio- 

and factors discharged home with engineered 

development discovered CD-ROM containing their tissues 

for heart unique genomic maps, with available for 

disease, summaries of CVD, of which all heart and 

including they may be at increased vascular 

bacteria structures, 
and viruses. 

External glucose sensor will 
drive insulin pumps to 
deliver continuous 
microdoses of insulin. 

Vaccine produced to switch 
off nicotine receptors. 

Convention on Food ratified Convention 

(covering content, labelling, on universal 

taxation, advertising). access to 
essential 

Millennium Development preventive 

Goals (201 5): access to health care, 

affordable essential drugs in and 

developing countries principles of 

provided, in cooperation equity in 

with pharmaceutical quality care 

companies. delivery. 



UN WHO 

Conventions Framework 
and Goals Convention 
on Tobacco 
Control (FCTO 
ratified. 

WHO Global 
Strategy on 
Chronic 
Diseases, 
Diet and 
Physical 
Inactivity 
(2004). 



Artificial Heart 
body parts 
developed 



Transplant 
surgery 



High 
technology 



Medication 



luni)'. lir.im.idil orr. 

Nerves to 
transplanted 

hr.irf. 

Xenotransplantatlon Pig-napping of 

with pig hearts soars personal 

as rejection problem transgenic pigs a 

overcome. new crime. 



Nano-surgeons, or sub- 
microscopic robots, will 
crawl through arteries, 
scraping away fatty 
deposits and repairing 
damaged or diseased 
parts. 

Angiogenesis, the 
growth of new blood 

/rv.rl-., m.if l.r. ,,,,<r 

an alternative to 
coronary bypass, 
angioplasty or clot- 
buster drugs. 



Computerized 
"auto-doc" 
machine externally 
detects and treats 
illness by magnetic 

Off-pump beating 

hr,,rl -..H'l'T/ 

predominates. 

Automated 
external 
defibrillators 
offered as f- . 
electronic options 
in new homes for 
persons at high 

M'> .,1 VJ'I'I'T 

death, 



Six-drug "polypill" will 
reduce CVD by more 
than 80% if taken by 
everyone aged 55 and 
older, and everyone 
with existing CVD, 



Drugs developed 
to raise HDL- 



effective as 
statins are today 
for lowering LDL- 
cholesterol), 



75 





























TJ /"^T" 1 




- 


1 QC1 


A>I * 1 .*- '1 1J C f 




[3 v^ l-^ 1 


- 




L03Z 


Milestones in knowledge ol 












i . -| "ii* ^^ i 



lit 

I 






Palaeolithic era Spain Oldest 
anatomical drawing in El Pindal 

o 

cave of a mammoth with a dark 
smudge at the shoulder, which is 
thought to represent the heart. 



2698-2598 BCE China Huang Ti, 
the Yellow Emperor, was 
thousands of years ahead of his 
time in writing in Nei Ching 
(Canon of Medicine): "The blood 
current flows continuously in a 
circle without a beginning or end 

O O 

and never stops" and "all the blood 
is under control of the heart". He 
also recorded the association 
between salt intake and a 
"hardened pulse". 

1550 BCE Egypt Papyrus Ebers 
stated that after death the heart 
becomes the witness of the body's 
behaviour during life. To avoid 
incriminating testimony, the 
Egyptians buried the heart 
separately from the body. 






_L _i- 
600 BCE Greece Alcmaeon noted 

empty arteries in animals after 
death and inferred that arteries 
normally contained air. 

400 BCE Gree, 
Hippocrates, 
the Father of 
Medicine 
(460-370 BCE), 
challenged the 
belief that 
illness was 
caused by the 
^ gods; he 

o 

believed illness was caused by an 
imbalance of the four bodily 
humours: yellow bile, black bile, 
blood, and phlegm. He was also 
the first to recognize stroke. 

310-250 BCE Egypt Erasistratus 
described the heart, veins, arteries 
and valves, but claimed that 




arteries contained "pneuma" (air or 
spirit or soul), which was replaced 
each time a person breathed; when 

artery was cut, blood rushed in 

the pneuma escaped. 

& 131-201 CE 

Graeco-Roman 
physician 
Claudius Galen, 
with knowledge 
gained from 
animals killed 
by Roman 
gladiators, 




described the heart and the 
movement of blood in the arteries, 
but claimed that the liver was the 
ntre of the circulation and that 
the blood passed from the right to 
the left side of the heart. 

980-1037 Persia Avicenna 

(Ibn Sina) stated that the heart is 

located centrally to all organs of 

J O 

the body, and that the left side of 
the heart was created as a store of 
spirit and soul. 









1210-1288 Syria Ibn al-Nafis 
described the pulmonary and 
coronary circulation in 
he Perfect Man. 

1452-1519 Italy Leonardo da Vinci 
incorrectly drew the liver as the 
centre of circulation. But he stated 
"vessels in the elderly through the 
thickening of the tunics, restrict 
the transit of the blood." This is 
one of the earliest descriptions of 
arteriosclerosis. 



1553 Spain Michael Servetus 
described the pulmonary 
circulation in his book 
Christianismi Restitutio. 



1510-1559 Padua, Italy Matteo 
Realdo Colombo described the 
heart valves. 



1525-1603 Rome, Italy Andrea 
Cesalpino noted that the 
circulation system is a closed 
system, and was the first in 
modern times to coin the term 
"blood circulation". 

1553-1 61 9 /Wua, Italy 
Hieronymus Fabricius 
demonstrated valves in veins, 
which help to "prevent dilatation 
of veins". 



15 55 Padua, 
Italy Andreas 
Vesalius 
(1514-1564) 
stated that the 
heart, and not 
the liver, was 
the centre of the 
circulation. 



1 559 Italy Riva di Trento 
discovered that there are two 
coronary arteries, each supplying 
blood to half of the heart. 

1628 England William Harvey 
(1578-1657), a physician, 
published his thesis that the heart 
pumped blood around the body, 
in De Motu Cordis. 

mid- 1600s Switzerland 
Jacob Wepfer found that patients 
who died with "apoplexy" had 
bleeding in the brain. He also 
discovered that a blockage in one 
of the brain's blood vessels could 
cause apoplexy. 

1 706 France Anatomy professor 
Raymond de Vieussens first 
described the structure of the 
heart's chambers and vessels. 

1712-1 780 England John Fothergill 
both forecast the role of 
psychosocial factors and advised 



that a restricted diet "might greatly 
retard the progress" of coronary 
heart disease. 

1677-1761 England Stephen Hales, 
an English clergyman and scientist, 
first measured blood pressure In 
inserting a brass tube into the 
artery of a horse. This was a 
scientific experiment, published in 
1733, demonstrating that the heart 
exerts pressure in order to pump 
blood. The horse died. 

1745-1827 Italy Alessandro Volta 
discovered that electric energy was 
produced by heart muscle 
contractions. 

1 749-1 832 England Edward 
Jenncr, better know for smallpox 
vaccine, made the essential link 
between angina pectoris and 
disease of the coronary arteries. 

1752-1832 Italy Antonio Scarpa 
described arterial aneurvsm. 

1772 England 
William Heberden 
(1710-1801) 
described angina 
pectoris: "they who 
are afflicted with it, 
are sei/ed while 
thev are walking (especially if it be 
uphill, and soon after eating) with a 
painful and most disagreeable 
sensation in the breast, which seems 
as if it would extinguish life if it 
were to increase or to continue; but 
the moment they stand still, all this 
uneasiness vanishes". He was also 
the first to write about 
byperlipidaemia as a risk factor 
when he noticed that the serum of 
an obese patient who suddenly died 
was "thick like cream". 



1775 Scotland John Hunter (1728 
1793), a surgical pathologist, 
wrote "in a sudden and violent 
transport of anger, he fell down 
and expired immediately", 
illustrating the importance of 




emotion, stress and anger in 
precipitating coronary death. 
Hunter himself suffered from 
angina pectoris and died suddenly 
alter a violent argument with a 
hospital colleague. 

1785 England William Withering 
described the use of digitalis in 
coronary heart disease in his 
monograph An Account of the 
Foxglove. Foxglove had been used 
tor centuries bv American Indians. 



1791 Italy 
Luigi Galvani 
discovered that 
electrical 




L 



stimulation of a 
frog's heart led to 
contraction of the 
cardiac muscle. 



1799 England Caleb Hillier found 
something hard and gritty in the 
coronary arteries during an 
autopsy and "well remembered 
looking up to the ceiling, which 
was old and crumbling, conceivii 
that some plaster had fallen down". 
He discovered, however, that the 
vessels had hardened, and stated 
that "a principle cause of the 
syncope anginosa is to be looked 
for in disordered coronary 
arteries". 

1815 England London surgeon 
Joseph Hodgson claimed 
inflammation was the underlying 
cause of atherosclerosis and it was 
not a natural degenerative part of 
the ageing process. 

1815 France M.E. Chevreul name 
the fatty substance extracted from 
gallstones "cholesterol" from the 

O 

Greek "khole" (bile) and "stereos" 
(solid). 



symptoms as he was reluctant to 
apply his ear to the chest. 



1838 France Louis Rene Lecanu 
showed that cholesterol was 
present in human blood. 

1841 Austria Carl Von Rokitansky 
championed the thrombogenic 
theory, proposing that deposits 
observed in the inner layer of the 
arterial wall derived primarily 
from fibrin and other blood 
elements rather than being the 
result of a purulent process. This 
theory came under attack from 
Rudolf Virchow. 





f-t- 





H 

1843 J. Vogel showed that 
cholesterol was present in 
atherosclerotic plaques. 



1 844 Denmark 
First pathology 
report of plaque 
rupture in a 
coronary artery 
in Bertel 
Thorvaldsen, 
the celebrated 
neoclassical 

Danish artist and sculptor, who 
died of sudden cardiac death in the 
Royal Theatre in Copenhagen. 

1 850 Ventricular fibrillation first 
described. 

1850s Ophthalmoscope invented, 
allowing direct visualization of 

O 

arteries at the back of the eye. 

1852 England Fatty material in the 
coronary arteries described by Sir 
Richard Quain, which he 
attributed to nutrition. He linked 
the fatty heart to "languid and 
feeble circulation, a sense of 
uneasiness and oppression in the 
chest, embarrassment and distress 



1819 France Rene Theophile 
Laennec (1781-1826), invented 
the stethoscope. He rolled paper 
into a cylinder while examining a 
young woman with cardiac 

J o 

f 


in breathing, coma, syncope, 
angina pectoris, sudden death. . ." 


onzjq^ 








77 




1856 Germany 
Rudolf Virchow, 
a Pole, believed 
that disease 
occurred at 
cellular level, 
and also 
described 
cerebral emboli 
causing stroke. Virchow also 
emphasized the societal causes of 
disease as "disturbances of human 
culture". 



1867 England Lauder Brunton, 
pharmacologist, discovered that 
amyl nitrite relieved angina. 

lIIlXEtCEII 

1 872 France Gabriel Lippmann 
invented the capillary 
electrometer, the precursor of the 
electrocardiograph . 



: 



advertisements said that the drug 

o 

did "not affect the heart". 



1906 Germany M. Cremer, first 
oesophageal ECG by a professiona 
sword swallower. First fetal ECG 
from the abdominal surface of a 
pregnant woman. 

1 907 England First case report of 
atrial fibrillation by Arthur Cushnv 
professor of pharmacology at 
University College, London. 




1893 Holland Willem Einthoven 
(1 860-1927) introduced the term 
electrocardiogram or ECG/EKG; 
distinguished five deflections 
PQRST (1895); constructed the 
first electrocardiograph in 1901, 
which weighed 270 kg, occupi 
two rooms and required five 
people to operate it; transmitte 
the first ECG from hospital to his 
laboratory 1 . 5 km away via 
telephone cable (in 1905); 
published the first normal an< 
abnormal ECGs (1906) and won 
the Nobel Prize (1924). 




1912 James B. Herrick described 
heart disease resulting from 
hardening of the arteries. 



1912 First human cardiac 
catheterization (no X-ray 
visualization) by Frizt Bleichroeder, 
E. Linger and W. Loeb. 

1915 USA Establishment of 
organization in New York City, 
which became the American Heart 
Association. 

920 USA First ECG of acute 




yocardial infarction by Harold 




1 895 Germany Physicist Wilhem 
Konrad Roentgen (1845-1923) 



1923 USA First operative widening 
of scarred cardiac valve by 
E. Cutler and S.A. Levine. 

^L 
1 925 United Kingdom Widening of 

narrowed mitral valve by Souter, 
who stretched the valve ring with 
his fingers. 





disco\ 


ered X-rays, which ar 
o visualize the heart. 

T : 


e still 








' 




used t 













1896/ta/jScif 
invented the s 
to measure bl< 

1897 The intr 
aspirin. In one 
ironies, Bayer 


lione Riva- 
jhygmoma 
)od pressur 

aduction o 
of life's lit 
s first aspii 


& 

10 

e. 

in 
tic- 
in 


CCl 

m 
od 


tei 

en 


\ 






bl 

to 

ac 
V 










n 

hi 






1 






















U! 

























































1928 United Kingdom 

Sir Alexander Fleming discovered 

O 

penicillin, which is used to treat 
umatic fever. 




Apoplexy" divided into 
tegories based on the cause of the 
blood vessel problem, and replaced 
by the term "cerebral vascular 
accident (CVA)". 

1 929 Germany First documented 
right heart catheterization in 



1931 USA First description of the 
use of exercise to provoke attacks 
of angina pectoris by Charles 
Wolferth and Francis Wood. 



1931 USA 

First artificial 

cardiac 

pacemaker, 

which 

stimulated 

the heart by 

transthoracic 

needle, 

developed 



bv Dr Albert Hvman. 



1937 USA First prototype heart- 
lung machine built by physician 
John Heysham Gibbon, and tested 
on animals. He performed the first 
human open heart operation in 
1953 using the machine. 

1938 USA First human heart 
surgery, first surgical correction o: 
a congenital heart defect: closure 

o 

of patent ductus arteriosus 
performed by surgeon 
Robert E. Gross. 

1944 China First repair of patent 
ductus arteriosus in China. 

1 944 USA First operation on "blue 
baby" (Fallot's tetralogy) at Johns 
Hopkins. 






human by Werner Forssmann 
using radiographic techniques. 



1944 USA /Sweden First repair of 
coarctation of aorta by Crafoord 
and Grosse. 



1947 USA First 
defibrillation 
of human heart 
during cardiac 

O 

surgery, by 
Claude Beck in 
Cleveland. 





1948 USA "Blind finger" closed 
heart surgery for mitral stenosis 
reintroduced by Dr Dwight 
Harken and Dr Charles Bailey. 









1948 USA California physician 
I a\\ rrnce Craven noticed that 400 
of his male patients who took 
aspirin tor two years had no heart 
attacks. By 1956, he had 
chronicled the health of 8000 
patients taking aspirin and found 
no heart attacks in the group. 

1948 USA Start of the Framingham 
Heart Study where, for the first 
time, a large cohort of healthy men 
and women were studied 
prospectively. 



1954 United Kingdom First carotid 
endarterectomy by Eastcott, 
Pickering and Rob. 



1954 India Called on WHO to 
address the coming epidemic of 
cardiovascular disease in 
developing countries. 



'55 United Kingdom First reportec 



1949 USA Portable Holter Monitor 
invented bv Norman Jeff Holter to 
record ambulatorv ECG. 

1950 The International Society of 
Cardiology established, later joined 
with International Cardiology 
Federation and renamed World 
Heart Federation. 

1 950 Canada First pacemaker 
invented by John Hopps. 

1952 USA First prosthetic valve 
implanted in aorta by surgeon 
Charles Hufnagel. 

1952 USA First successful human 
open heart surgery under 
hypothermia bv Walton Lillehei 
and John Lewis, who implanted 
the first synthetic valve in a 
live year-old girl who had been 
born with an atrioseptal defect 
(hole in her heart). 

1952 USA External cardiac 
pacemaker designed by Paul Zoll. 




itral valve replacement by Judson 
Chesterman. 

950s Minimization of bias for the 

le assessment of 
cardiovascular treatments by 
introduction of randomization into 
clinical trials (at instigation of Sir 
Austin Bradford Hill). 




1960 USA First 
replacement of 
heart valve with 
Starr- Ed wards 
mechanical valve, 
developed by 
Albert Starr (left) 
and Lowell 
Edwards. 



1956 USA First report of the 
successful ending of ventricular 
fibrillation in humans by externally 
applied countershock published by 
Dr Paul Zoll. 



1957 First battery-powered 



external pacemaker. 






1 958 USA Seymour Furman 
inserted a pacemaker in a patient 
lived for 96 days. 





1958 Sweden Internal long-term 
cardiac pacing by Ake Senning. 




1953 USA First 
demonstrated 






programme. 

;"- 



coronary artery 
disease among 
young US 
soldiers killed in 
action in Korea 
(later observed in 
the casualties of the Viet Nam Wa 
too) by William F. Enos, Robert 



H. Holmes and James Beyer. 






1 958 Start of development of a 
selective coronary angiography 
procedure by Mason Sones. 



1959 WHO established 
Cardiovascular Diseases 






1 960s High blood pressure 
identified as a treatable risk factor 
for stroke . 






1960 USA First Coronary Care 
Unit in Bethany, Kansas. 

1960 Framingham, USA Cigarette 
smoking found to increase the risk 
of heart disease. 







._ 



1961 USA Framingham Heart 
Study investigators coined the term 
"risk factors" for the development 
of coronary heart disease. High 
cholesterol level, blood pressure, 
and electrocardiogram 
abnormalities found to increase the 
risk of coronary heart disease. 

-j-4 

1961 USA First use of external 
cardiac massage to restart a heart 
byJ.R. Jude. 

1961 USA First direct current 
dcfibrillation with external paddle; 
by Bernard Lown and Barough 
Berkowitz. 



1960s First human implant of 
totally implantable pacemak 

1964 USA First transluminal 
angioplasty performed on a 
narrowed artery in the leg by- 
Charles T. Dotter. 



1965 USA Michael DeBakey am 
Adrian Kantrowitz implanted 
mechanical devices to help a 
diseased heart. 







1967 South Ajrica First whole heart 
transplant from one person to 
another by Dr Christiaan Barnard. 

1 967 USA Saphenous vein coron 
bypass graft by Dr Rene Favaloro. 

1967 Framingham, USA Physical 
inactivity and obesity found to 
increase the risk of heart disease. 








1969 USA First use of artificial 
heart in human by Denton Cooley. 

1972 USA The Stanford Three 
Community Study started (later 
becoming The Stanford Five-City 
Project); this showed a 23% 
reduction in coronary heart disease 
risk caused by community-based 
interventions that change lifestyle- 
related risk factors such as physical 
activity, dietary habits and tobacco 



1972 Finland North Karelia Project 
began, aimed at preventing 
cardiovascular disease among 
residents. Cardiovascular mortality 
rates for men, aged between 
35 and 64 years, decreased by 57% 
from 1970 to 1992. 

1974 Framingham, USA Diabetes 
linked to cardiovascular disease. 



1 970s Aspirin recognized as 

preventing heart attacks and 

i 

stroke. 



1970s Development of 
computerized tomography (CT) to 
aid early diagnosis of stroke . 




1977 

Switzerland 

First coronary 

PTCA 

(percutaneous 

transluminal 

coronary 

angioplasty); 

Andreas 

Gruentzif 

He- 
inserted a balloon-tipped catheter 

into a coronary artery and inflated 
the balloon, and thus successfully 
opened a blockage and restored 
blood flow. 




1977 Italy The Martignacco Project 
community prevention trial 



resulted in reduction of coronary 
heart disease through community- 
>ased interventions that change 
lifestyle-related risk factors such as 
physical activity, dietary habits and 
tobacco use. 



1977 Framingham, USA Effects 
described of triglycerides and LDL- 
and HDL- cholesterol on heart 
disease. 



1978 Framingham, USA 
Psvchosocial factors found to affect 
heart disease. 





1978 Australia North Coast Healthy 
Lifestyle Programme showed 

significant reduction in smoking. 

5 & 

1978 Switzerland Swiss National 
Research Programme community 
prevention trial resulted in 
reduction of smoking, blood 
pressure and obesity. 

1978 Atrial fibrillation (irregular 
heart beat) found to increase the 
risk of stroke . 

1979 South Africa Coronary Risk 
Factor Study community 
prevention trial resulted in 
reduction of smoking, blood 
pressure and composite coronary 
heart disease risks. 






1983 USA List of 246 coronary risk 
factors published by Hopkins and 
Williams (list now much longer). 

1980s Minimization of random 
error for the reliable assessment of 
cardiovascular treatments by 
introduction of large-scale "mega- 
trials" (at instigation of Sir Richard 
Peto). 



1979 Germany First use by Peter 
Rentrop of intracoronary 
streptokinase, a clot-dissolving drug 
to stop a heart attack in progress. 

1981 Framingham, USA Filter 
cigarettes found to carry as much 
risk for coronary heart disease as 
unfiltered cigarettes. 



1981 USA Report on relationship 
between diet and heart disease. 



1982 USA First permanent artificial 
heart, designed by Robert Jarvik, 
and implanted by Willem DeVries, 
in a 61 -year-old man. 

* 







1 986 France First coronary stent 
implanted by Jacques Puel and 
Ulrich Sigwart. 

1987 Japan M. Okada used a laser 
to burn channels in the heart 
muscle to help revascularize the 
heart in patients with coronary 
heart disease. 

1 987 Framingham, USA High blood 
cholesterol levels found to 
correlate directly with risk of death 
in young men. 

J O 

1988 Framingham, USA High levels 
of HDL-cholesterol found to 
reduce risk of death. 



1988 ISIS- 2 trial 
shows 
emergency 
treatment for 
heart attacks 
with aspirin and 
fibrinolytic "clot- 
busting" drugs 
saves lives. 




~~H^H 
1988 Framingham, USA Isolated 

systolic hypertension found to 
increase risk of heart disease. 

1 988 Framingham, USA Cigarette 
smoking found to increase risk of 
stroke. 



1990 Randomized trials showed 
that lowering blood pressure 
lowers the risk of stroke. 

1990 United Kingdom Meta-analysis 
of trials by Clinical Trial Service 
Unit (CTSU) in Oxford showed 



that lowering blood pressure 
lowers the risk of coronarv disease. 

1991 China Tianjin CVD 
Intervention Programme 
community prevention trial led to 
the creation of non-smoking 

O 

environments and increased sales 
ol low-sodium seasonings. 



Ilh/IIla receptor blockcr drugs 
prevent blood clots; the 
importance of inflammation in 
cardiovascular disease recognized; 

O 

study on the deadly effects of 
smoking fewer than 1 cigarettes 
per day. 



re 



1 992 Canada The Victoria 
Declaration on Heart Health 
affirmed that CVD is large Iv 
preventable, that there is the 
scientific knowledge to eliminate 
most CVD, and that the public 
health infrastructure and capacity 
to address prevention were 
lacking. 

1990s USA Hostility (including 
traits such as anger, cynicism, and 
mistrust), a major component of 
type A behaviour, shown to be 
associated with an increased risk of 
heart attack and other cardiac 
complications in healthy persons 
and patients with coronary heart 
disease. 

1992 China First heart-lung 
transplant in China. 



mid-1990s Scandinavia, United 
Kingdom, USA Remarkable 
improvement in survival of 
coronary heart disease patients 
treated with statins. 




1 998 Singapore The Singapo 
Declaration: Forging the Will 

O O 

Heart Health in the Next 
Millennium. 



2000 Canada The 
Victoria 
Declaration on 
Women, Heart 
Disease and 
Stroke addressed 
the importance of 
science and polic 
in action and the need to tackle 
gender disparities in health. It 
called upon all stakeholders to join 
forces and take appropriate actio 
to control the cardiovascular 
disease epidemic. 






1 995 Spain The Catalonia 
Declaration: Investing in Heart 
Health, and its follow-up 
convention in 1997, emphasized 
the importance of investments in 
heart health and provided examples 
of many successful CVD prevention 
programmes worldwide. 



2000 First World HeartJOay, whu 
has become a global annual event. 

2000 The entire human genome is 
mapped. 

2000 WHO 53rd World Health 
Assembly endorsed Global strateg' 
for noncommunicable disease 
(NCD) prevention and control, 
which outlines major objectives for 
monitoring, preventing and 
managing NCDs with special 
emphasis on major NCDs with 
common risk factors and 
determinants cardiovascular 
disease, cancer, diabetes and 
chronic respiratory disease. 



Cardiovascular Disease emphasized 
the global nature of the CVD 
burden and highlighted the need to 
address economic and political 
factors in order to tackle CVD. 

2002 United Kingdom The Heart 
Protection Study showed that 
statins could benefit people with 
diabetes and those with cholesterol 




levels previously considered low. 

1 J 

2002 USA 

NASA's 
Commercial 
Invention of the 
Year Award 
given for the 
DeBakey 
Ventricular 
Assist Device, 
based on space shuttle technology, 
and developed by Michael 
DeBakey (above) and NASA 
engineer David Saucier. The 
pump, used to treat heart failure, 
was one-tenth the size of previous 
heart-assist devices, and was first 
used in a patient in 2000. 

2003 Switzerland WHO 
Framework Convention on 
Tobacco Control adopted at the 

56th World Health Assembly. 

J 



1998 USA Hypertension gene in 
men identified. 

1998 New advances: 



gene therapy grows new blood 
vessels to the heart; strong 

confirmation that "superaspirin" 
1 * 




2001 Japan The 
Osaka 

Declaration: 
Health, 
Economics and 
Political Action: 
Stemming the 
Global Tide of 



2003 Switzerland The World 
Health Report: "Shaping the 
Future" highlighted CVD as the 
first of three growing threats that 

O O 

make up the "neglected global 
epidemics". The report called for 
action at the national and global 

O 

levels to prevent and control CVD. 



2004 Switzerland WHO Global 
Strategy on Diet, Physical 



Activity and Health endorsed by 
World Health Assembly. 

2004 Italy Milan Declaration on 
Heart Health: Positioning 

O 

Technology to serve Global Heart 
Health. 











%'* 

f 




PART 6 




WORLD TABLES 



"Live as if you were to die tomorrow. Learn as if you were 
to live forever." 



Mahatma Gandhi (1869 1948) 



83 



World Data Table 



Country 

Afghanistan 


i 

Population 

Thousands 
2002 

22930 


2 
Heart disc 
Disability 

DALYS lost |HT 1000 
population 
2002 
36 


ase 


3 
Stroke 


4 
Rheumatic 
heart disease 

Number of deaths 

2002 

1 938 


Mortality 
Number 

ol 'deaths 
2002 
33 157 


Disability 

DAI.YS lost per 1000 
population 
2003 or Idlest iii(j//()/)/r ,/,,! 

13 


Mortality 
Number 

ol deaths 
2002 
11 532 


Albania 


3 141 13 


3989 


13 


4 169 


42 


Algeria 


31 266 7 


14948 


8 


16223 


756 


Andorra 


69 3 


67 


3 52 


3 


Angola 


13 184 13 


7 130 


15 7 640 


615 


Antigua and Barbuda 


73 6 


52 


13 


92 





Argentina 


37 981 6 


34292 


6 


22 668 


234 


Armenia 


3072 


20 


8515 


10 


4212 


151 


Australia 


19544 5 25474 


3 


11 730 


243 


Austria 


8 111 6 15418 


4 


7 559 


185 


Azerbaijan 


8297 


28 


22302 


9 


6 540 


184 


Bahamas 


310 5 154 6 


155 


1 


Bahrain 


709 8 283 3 


84 


6 


Bangladesh 


143809 18 


130006 


9 


64515 


10253 


Barbados 


269 6 


286 


7 


270 


2 


Belarus 


9940 28 


59 719 


14 


22 892 


550 


Belgium 


10296 5 


14985 


4 


9 234 


68 


Belize 


251 8 


153 


7 


111 


1 


Benin 


6 558 10 


3017 


12 


3 279 


236 


Bhutan 


2 190 20 


2672 


10 


1 370 


195 


Bolivia 


8645 6 


3948 


7 


3 138 


70 


Bosnia and Herzegovina 


4 126 


10 


5590 


13 


6508 


21 


Botswana 


1 770 8 


697 


8 


670 


15 


Brazil 


176257 9 


139601 


11 


129 172 


3055 


Brunei Darussalam 


350 


5 


92 


6 


90 


7 


Bulgaria 


7965 14 


26243 


13 


20882 


232 


Burkina Faso 


12624 11 


5877 


13 


6604 


466 


Burundi 


6602 


10 


3084 


12 


3 492 


82 


Cambodia 


13810 


13 


7635 


11 


5963 


614 


Cameroon 


15729 


10 


9443 


12 


10 198 


621 


Canada 


31 271 


5 


43246 


3 


15621 


422 


Cape Verde 


454 


6 


202 


Q 


266 


4 


Central African Rep. 


3 819 


10 


2 513 


12 


2 727 


51 


Chad 


8348 


10 


4385 


12 


4747 


300 


Chile 


15613 


4 


9075 


5 


8 142 


315 


China 


1 294 867 


4 


702 925 


12 


1 652 885 


97 245 


Colombia 


43 526 


8 


31 289 


6 


17 745 


380 


Comoros 


747 


8 


282 


10 


310 


23 


Congo 


3633 


9 


1 577 


10 1 718 


39 


Congo, Dem. Rep. 


51 201 11 


24217 


13 


26439 


1 930 


Cook Islands 


18 10 


11 


12 


11 





Costa Rica 


4094 


6 


2937 


3 


1 194 


45 


Cote d'lvoire 


16365 


11 


9257 


12 


9530 


233 


Croatia 


4439 


10 


11 653 


11 


8653 


152 


Cuba 


11 271 


8 


16275 


5 


7 684 


196 


Cyprus 


796 


7 


1 358 


3 


795 


1 


Czech Republic 


10246 


11 


25899 


7 


15663 


286 


Denmark 


5351 


5 


10013 


4 


4871 


17 


84 





imoking prevalence 

Percentage ol people 1 N 
ears and above who smoke 
.W.J or latest available Jata 



46.2% 22.8% 

40.2% 11.5% 

49.6% 35.9% 



32.0% 
67.4% 
30.706 
37.4% 
32.0% 

29.5% 
63.0% 
19.8% 
63.60/0 
33.2o/o 



36.7% 
54.6% 



29.4% 



47.3o/o 
25.6% 



20.70/0 
30.0o/o 



19.7% 

44.1% 
58.9% 

30.5% 
20.806 



24.3% 
21.0% 
41.4% 
48.8% 

42.6% 
40.3% 



18.90/0 

4.1o/o 

23.1% 

26.3% 

1.706 

16.0% 
34.506 
3.0% 
22.00/0 
22.906 

5.4o/o 

19.20/0 
31.5% 

18.406 

28.206 
13.2% 

6.50/0 

2.40/o 

26.6% 



3.1% 

36.6% 

3.6% 

18.4% 
3.9% 



10.0% 

4.0% 

27.4% 

28.5% 

26.2% 
36.9% 



6 
Diabetes 

I'erc enlace ol |>eople 
ji <l 'II \ears and alxive 
with dialx-tes 
2000 


7 
Ki-search 

Number D| publications 
mi c ardio\ast ular disease 
1991 2001 


8 
Policies ami 
legislation 

Ix-gal st. it us K| smoking 
in government building 
2004 or latest available data 


4.7% 


- 


unknown 


4.5% 


- 


not regulated 


2.6% 


1 


unknown 


8.8% 


- 


banned 


0.9% 


HHHHHHH 


not regulated 


7.3% 


- 


unknown 


6.1% 


110 


not regulated 


4.7% 


1 


not regulated 


6.8% 


710 


restricted 


3.8% 


320 


restricted 


6.8% 


1 


banned 


6.2% 


- 


unknown 


9.1% 


4 


unknown 


4.6% 


3 


restricted 


5.8% 


1 


banned 


9.9% 


3 


restricted 


4.0% 


345 


restricted 


4.2% 


- 


restricted 


3.3% 


1 


unknown 


3.5% 


- 


unknown 


4.9% 


HHHHHHI 


restricted 


3.8% 


- 


banned 


3.6% 


HHHHHHH 


restricted 


4.3% 


307 


banned 


9.4% 


HHHHHHI 


banned 


7.70/0 


18 


banned 


2.7% 


2 


not regulated 


1.0% 


- 


not regulated 


1.9% 


HHHHHHI 


restricted 


1.0% 


4 


restricted 


8.8% 


1 237 


restricted 


3.4% 


- 


restricted 


1.0% 


HHHHHHH 


not regulated 


2.8% 


- 


not regulated 


5.2% 


53 


restricted 


2.4% 


472 


restricted 


3.6% 


11 


unknown 


1.4% 


- 


unknown 


1.1% 


2 


restricted 


1.4% 


- 


unknown 


6.3% 


HHHHHHI 


not regulated 


3.3% 


2 


restricted 


3.6% 


HHHHHHH 


restricted 


4.4% 


41 


banned 


6.0% 


15 


restricted 


9.2% 


- 


restricted 


4.3% 


78 


banned 


3.8% 


308 


restricted 



Country 



Afghanistan 

Albania 

Algeria 

Andorra 

Angola 

Antigua and Barbuda 

Argentina 

Armenia 

Australia 

Austria 

Azerbaijan 

Bahamas 

Bahrain 

Bangladesh 

Barbados 

Belarus 

Belgium 

Belize 

Benin 

Bhutan 

Bolivia 

Bosnia and Herzegovina 

Botswana 

Brazil 

Brunei Darussalam 

Bulgaria 

Burkina Faso 

Burundi 

Cambodia 

Cameroon 

Canada 

Cape Verde 

Central African Rep. 

Chad 

Chile 

China 

Colombia 

Comoros 

Congo 

Congo, Dem. Rep. 

Cook Islands 

Costa Rica 

Cote d'lvoire 

Croatia 

Cuba 

Cyprus 

Czech Republic 
Denmark 

85 



World Data Table 



Country 


1 2 3 
Population Heart disease Stroke 


4 
Rheumatic 
heart diseas 

Number of deat 
2002 


Thousands i Disability Mortality Disability Mortality 
2002 ! DALYS lost per 1000 Number DA LYS lost per 1000 Number 
population of deaths population of deaths 
2002 2002 2003 or latest available data 2002 


Djibouti 


693 21 


727 7 248 


27 


Dominica 


78 3 


30 4 30 





Dominican Republic 


8616 11 


7 271 9 4 833 


54 


Ecuador 


12810 5 


5 826 5 4 374 


117 


Egypt 


70 507 21 103 829 8 


35054 


3398 


El Salvador 


6415 10 


5328 4 


1 684 


39 


Equatorial Guinea 


481 11 


313 12 


333 


18 


Eritrea 


3991 9 


1 326 10 1 474 


42 


Estonia 


1 338 16 


6 235 9 2 964 


65 


Ethiopia 


68 961 10 


32477 11 35329 


2 482 


Fiji 


831 18 


783 17 685 


21 


Finland 


5 197 7 


12488 4 4875 


77 


France 


59 850 3 


46132 3 37750 


1 136 


Gabon 


1 306 11 


1 001 11 951 


57 


Gambia 


1 388 10 


789 11 


837 


48 


Georgia 


5177 23 


26035 17 15680 


59 


Germany 


82414 6 172717 4 


79326 


2 241 


Ghana 


20471 9 


10471 11 11 337 


705 


Greece 


10970 7 


16825 6 22694 


10 


Grenada 


80 9 


85 13 


91 


1 


Guatemala 


12036 4 


2 796 4 


2232 


14 


Guinea 


8359 11 


4137 12 


4415 


289 


Guinea-Bissau 


1 449 11 


783 13 




844 


52 


Guyana 


764 12 


791 18 


880 


8 


Haiti 


8218 5 


2469 16 


6764 


62 


Honduras 


6781 , 10 


4 544 8 


2 786 


79 


Hungary 


9923 13 


29 502 8 


17 148 


354 


Iceland 


287 5 


416 3 189 


3 


India 


1 049 549 20 1 531 534 10 771 067 


103913 


Indonesia 


217 131 14 220372 8 123 684 


11 660 


Iran, Isl. Rep. 


68070 17 


81 983 8 31 768 


1 138 


Iraq 


24510 19 


22 036 8 8 291 


695 


Ireland 


3911 8 


6 527 4 2 650 


51 


Israel 


6304 4 


5 705 3 2 233 


170 


Italy 


57 482 4 


92 928 4 69 075 


1 790 


Jamaica 


2627 5 


1 877 11 


3 559 


59 


Japan 


127478 3 


90 196 5 


134952 


2 585 


Jordan 


5329 13 


3 788 6 


1 428 


127 


Kazakhstan 


15469 28 


51 948 17 


26874 


919 


Kenya 
Kiribati 


31 540 9 
87 1 


13661 10 
7 18 


14843 
81 


360 

o 


Korea, Dem. People's Rep. of 


22 541 13 


26 953 8 


14337 


1 317 


Korea, Republic of 


47 430 3 


15811 9 


46 151 


202 


Kuwait 


2 443 10 


940 3 


213 


7 


Kyrgyzstan 


5 067 22 


10 850 22 


8366 


351 


Lao People's Dem. Rep. 


5529 19 


5539 12 


3 620 


484 


Latvia 


2329 17 


9928 12 


7278 


109 


Lebanon 


3596 17 


5471 7 


2072 


119 


86 









5 6 


7 8 




Smoking prevalence Diabetes 


Research Policies and 




Percentage 


of people 18 fcroeotage of people Number of publications legislation 


Country 


c.irs .mil -ilicnr \\ ho smoke aged 20 vears and above on cardiovascular disease 


Legal status of smoking 




2003 or lute*! atailahlc data with diabcU-s 1991- 2001 


in government buildings 




men 


women 2000 


2004 or latest available data 




- 


2.50/0 


unknown 


Djibouti 


- 


| - 6.20/0 


unknown 


Dominica 


22.1% 


16.2% 5.2o/o HH 


restricted 


Dominican Republic 


31.9% 


7.4% 4.80/0 3 


banned Ecuador 


47.9% 


1 .80/0 7.20/o 


20 


restricted Egypt 


- 


3.0% unknown El Salvador 


- 


3.8o/o 


- 


unknown 


Equatorial Guinea 


- 


2.8o/o 


4 


not regulated 


Eritrea 


57.1% 


28.8% 4.4o/o 


7 


banned 


Estonia 


9.7% 


0.8% 2.80/0 


4 


not regulated 


Ethiopia 


47.3% 


14.0% 8.30/0 


1 


not regulated 


Fiji 


31.6% 


22.3% 3.90/o 


331 


banned 


Finland 


42.6% 


33.9o/o 3.9% 


1 407 


restricted 


France 


- 


1.20/o 


not regulated 


Gabon 


43.40/0 


6.20/o 3.3% 


4 


restricted 


Gambia 


61 .4% 


6.30/o 


5.30/0 


159 


not regulated 


Georgia 


39.0% 


30.90/0 


4.1o/o 


2276 


restricted 


Germany 


1 4.2% 


1 .9% 


3.3o/o 


1 


restricted 


Ghana 


53.5% 


33.6% 


10.30/0 


245 


restricted 


Greece 


- 


- 


7.30/o 


- 


unknown 


Grenada 


24.5% 


3.70/o 


2.70/o 


HHHHHHi 


restricted 


Guatemala 


- 




0.9% 3 


banned 


Guinea 


! 


3.1o/o 


HHHHUHJi 


not regulated 


Guinea-Bissau 


- 


- 


4.20/o 


unknown 


Guyana 


25.2% 


5.4o/o 


4.1o/o 


- 


unknown 


Haiti 


- 


2.70/o 


unknown 


Honduras 


47.2% 


27.70/0 


4.40/o 


103 


banned 


Hungary 


26.5% 


27.1o/o 3.20/0 9 banned 


Iceland 


34.6% 


3.4o/o 5.5o/o 294 


banned 


India 


59.8% 


5.3o/o 6JO/o 


4 


restricted 


Indonesia 


33.4% 


3.5o/o 


6.0% 


- 


banned 


Iran, Isl. Rep. 


- 


- 


6.1o/o 


1 


unknown 


Iraq 


33.8% 


26.5o/o 


3.2o/o 


142 


restricted 


Ireland 


35.8% 


19jo/o 6.70/0 


634 


banned 


Israel 


37.9% 


29jo/o 


9.20/0 


1 976 


banned 


Italy 


56.10/0 


21.2% 


5.40/o 


23 


not regulated 


Jamaica 


52.5% 


12.4% 


6.70/o 


3 769 


restricted 


Japan 


66.80/0 


5.3% 


8.10/0 


6 


banned 


Jordan 


57.50/0 


6.40/o 


4.40/o 


HHHHHH 


restricted 


Kazakhstan 


66.3o/o 


27.30/0 


1.4% 


3 


not regulated 


Kenya 


m 


HHHI 


8.60/o 


- 


not regulated 


Kiribati 


- 


- 


2.50/0 


- 


unknown Korea, Dem. People's Rep. of 


69.5o/o 


5.10/0 


5.60/0 


19 


restricted Korea, Republic of 


35.7% 


2.70/0 


9.8o/o 


17 


restricted 


Kuwait 


64.1% 


41.4% 


3.6% 


HHHHHH 


not regulated 


Kyrgyzstan 


68.90/0 


16.1% 


1.8% 


- 


restricted 


Lao People's Dem. Rep. 


64.50/0 


29.20/0 


4.50A) 


1 


restricted 


Latvia 


60.70/0 


46.90/0 


7.00/0 


65 


restricted 


Lebanon 




87 



World Data Table 



Country 


i 

Population 

Thousands 
2002 


2 
Heart disease 


3 
Stroke 


4 
Rheumatic 
heart diseas 

Number of deal 

2002 


Disability Mortality Disability Mortality 

DALYS lost per 1000 Number DALYS lost per 1000 Number 
population of deaths population of deaths 
2002 2002 ; 2003 or latest available data 2002 


Lesotho 


1 800 


9 


1 200 11 


1 299 


24 


Liberia 


3 239 


12 


1 442 14 1 559 


130 


Libyan Arab Jamahiriya 


5445 


15 


5 309 6 1 762 


130 


Lithuania 3 465 


16 14662 7 5089 


186 


Luxembourg 


447 


4 


455 5 390 





Macedonia, Former Yugos. Rep. of 2 046 


9 


2544 13 


3 772 


41 


Madagascar 


16916 


10 


8327 11 


9020 


609 


Malawi 


11 871 


10 


6773 11 


7 249 


106 


Malaysia 


23965 


8 13445 7 


10 169 


464 


Maldives 


309 


17 


282 10 


152 


16 


Mali 


12623 


11 


5406 13 


5946 


478 


Malta 


393 


9 


865 4 


338 


6 


Marshall Islands 


52 


20 


57 20 


54 


2 


Mauritania 


2807 


11 


1 640 13 


1 756 


111 


Mauritius 


1 210 


18 2034 11 


1 235 


5 


Mexico 


101 965 


6 51 454 4 


26478 


1 093 


Micronesia, Federated States of 


108 


12 


64 14 


69 


2 


Moldova, Republic of 


4270 


23 1 


8559 15 


7 848 


264 


Monaco 


34 


3 


27 3 


22 


1 


Mongolia 


2 559 


8 


1 153 25 


2 515 


145 


Morocco 


30072 


14 29934 5 


10607 


808 


Mozambique 


18537 


8 


7 969 10 


8896 


246 


Myanmar 


48852 


17 58478 11 


33 406 


3 746 


Namibia 


1 961 


8 


996 10 


1 108 


25 


Nauru 


13 


22 


17 10 


7 





Nepal 


24609 


18 23314 10 


11 961 


1 648 


Netherlands 


16067 


5 1 


9045 4 


12459 


16 


New Zealand 


3 846 


7 


6 141 4 


2 699 


139 


Nicaragua 


5335 


8 


2 680 7 


1 768 


70 


Niger 
Nigeria 


11 544 
120911 


11 4423 13 
11 64778 12 


4831 
69932 


439 
4795 


Niue 

Norway 


2 
4514 


10 
5 


1 12 

8 886 3 


1 

4817 



103 


Oman 


2768 


17 


1 765 4 


375 


12 


Pakistan 


149911 


18 154338 9 


78 512 


11 604 


Palau 
Panama 


20 
3064 


14 
5 


17 14 
1 628 5 


16 
1 489 



30 


Papua New Guinea 


5586 


18 


3 994 10 


1 960 


351 


Paraguay 


5740 


7 


2 606 10 


2881 


36 


Peru 


26 767 


4 10615 4 


8084 


157 


Philippines 


78 580 


10 4 


5378 7 


24368 


2812 


Poland 


38622 


10 7 


7 151 7 


43032 


1 277 


Portugal 


10049 


5 1 


0927 9 


20069 


189 


Qatar 


601 
22387 


9 238 4 
13 60718 13 


75 
52272 


4 
566 


Russian Federation 


144082 


27 674881 19 


517424 


8 126 


Rwanda 


8272 


10 3 493 12 


3811 


101 


Saint Kitts and Nevis 


42 


10 


46 19 


84 





88 









5 
moking prevalence 
Percentage ol people IN 

ars and lbove \\lio smoke 
(Hb 1 i>r Aiiiv ,ir.;i/<iMr i/iitj 
nu'ii women 


6 7 
Diabetes Research 

Percentage of people Numl>iT of publications 
aged 2(1 ve.irs ami abo\e on cardiovascular disease 
\\ithdiabetcs 1W1 .'()()/ 

2000 


8 
Policies and 
legislation 

; Legal status of smoking 
in government buildings 

o o 
2004 or latest available Jata 


Country 


- 


- 


3.1% 


unknown Lesotho 


- 


i 


3.10/0 


unknown 


Liberia 


- 


pHHHi 


3.1% banned 


Libyan Arab Jamahiriya 


46.4% 


15.90/0 


4.2o/o 5 restricted 


Lithuania 


41 .4% 


30.20/0 


3.6o/o 


3 


restricted 


Luxembourg 


- 


; 


3.8o/o 


5 banned Macedonia, Former Yugos. Rep. of 


- 


- 


1.4o/o 


2 not regulated Madagascar 


31.0% 


; 7.40/0 


1.1% 


1 not regulated 


Malawi 


52.40/0 


3.00/0 


7.60/o 


16 banned 


Malaysia 


- 


- 


5.0% 


banned 


Maldives 


26.9% 


4.70/o 


2.90/o 


restricted 


Mali 


DH^MBBMH 


- 


13.90/0 


5 not regulated 


Malta 




- 


8.60/o 


9 banned 


Marshall Islands 


25.0% 


i 4.30/o 


2.80/o 


not regulated 


Mauritania 


54.70/0 


3.10/0 


14.6% 


2 restricted 


Mauritius 


36.5% 


14.3% 


3.90/o 


201 restricted 


Mexico 


HH1 


IHHHi 


8.6% 


not regulated Micronesia, Federated States of 


- 


~ 


5.90/o 


I restricted Moldova, Republic of 







8.80/0 


7 


unknown 


Monaco 


46.20/0 


7.30/0 


2.50/o 


1 restricted 


Mongolia 


32.6Q/0 


0.60/o 


2.6o/o 


7 


restricted 


Morocco 


- 


- 


1.6o/o 


1 unknown 


Mozambique 


55.50/0 


12.20/0 


2.00/0 


mwmuam 


unknown 


Myanmar 


33.80/0 


16.1% 


3.10/0 


not regulated 


Namibia 


56.80/0 


64.70/0 


27.80/0 


banned 


Nauru 


61.5% 


34.60/0 


3.9% 3 banned 


Nepal 


38.30/0 


32.80/0 


3.5% 917 


restricted 


Netherlands 


28.10/0 


28.70/0 


6.70/0 131 restricted 


New Zealand 


HHI 


HHHHH 


2.90/0 


restricted 


Nicaragua 


- 


- 


2.50/0 


- 


unknown 


Niger 


16.30/0 


3.60/o 


3.4% 


18 


banned 


Nigeria 


36.80/0 


14.00/0 


6.30/0 


- 


restricted 


Niue 


40.3o/o 


39.00/0 


3.9% 


185 


restricted 


Norway 


23.60/0 


2.90/o 


9.9o/o 


19 


unknown 


Oman 


30.30/0 


3.80/o 


7jo/o 


12 


banned 


Pakistan 


50.9o/o 


22.6% 


8.60/0 


- 


banned 


Palau 


35.1% 


17.70/0 


3.5% 


1 


unknown 


Panama 


48.9% 


- 


6.50/o 


3 


banned 


Papua New Guinea 


45.80/0 


15.60/0 


3.70/o 




restricted 


Paraguay 


- 


- 


5.20/0 


3 restricted 


Peru 


59.6o/o 


13.8% 


7.10/0 


2 restricted 


Philippines 


51.50/0 


27.90/0 


4.1o/o 


187 banned 


Poland 


44.20/0 


19jo/o 


8.60/o 


51 


restricted 


Portugal 


- 


- 


10.10/0 


7 unknown 


Qatar 


33.3o/o 


10.80/0 


6.6o/o 


16 


unknown 


Romania 


58.10/0 


15.80/0 


4.20/o 


13 banned Russian Federation 


HHI 


HHHH 


0.9o/o 


not regulated Rwanda 


- 


- 


7.3% 


unknown Saint Kitts and Nevis 



89 



World Data Table 



Country 


i 

Population 

Thousands 
2002 


2 
Heart disease 


Stroke 


4 
Rheumati 
heart disea 

Number ot tie 
2002 


Disability 

DALYS lost per 1000 

population 
2002 


Mortality Disability Mortality 

Number DALYS lost per 1000 Number 
of deaths population of deaths 
2002 2003 or latest available data 2002 


Saint Lucia 


148 


6 


71 


11 120 


4 


Saint Vincent and Grenadines 


119 9 


103 10 88 


2 


Samoa 


176 14 


117 


14 128 


3 


San Marino 


27 5 


40 3 26 


1 


Sao Tome and Principe 


157 


7 


81 10 107 


2 


Saudi Arabia 


23 520 


17 


16438 4 3818 


126 


Senegal 


9855 


10 


3838 12 4154 


355 


Serbia and Montenegro 


10535 


12 


23 610 12 21 756 


238 


Seychelles 


80 


7 


54 2 15 


1 


Sierra Leone 


4764 


13 


2813 15 3035 


216 


Singapore 


4 183 


7 


3 946 3 1 716 


39 


Slovakia 


5398 


12 


14609 5 


4445 


131 


Slovenia 


1 986 


6 


2803 6 


2003 


87 


Solomon Islands 


463 


12 


213 13 


220 


6 


Somalia 


9480 


19 


6818 13 


4426 


333 


South Africa 


44759 


9 


27013 11 


30306 


792 


Spain 


40977 


4 


45018 3 


34880 


1 738 


Sri Lanka 


18910 


8 


16297 7 


13 348 


175 


Sudan 


32 878 


15 


28 458 10 


16532 


800 


Suriname 


432 


13 


397 


12 


362 


4 


Swaziland 


1 069 


8 


529 


8 


499 


13 


Sweden 


8867 


5 


20 122 3 


9 984 


143 


Switzerland 


7 171 


4 


10 746 2 


4 508 


112 


Syrian Arab Republic 
Tajikistan 


17381 
6 195 


13 
23 


11 168 
11 447 


11 
7 


7 675 
3 048 


1 715 
419 


Tanzania, United Republic of 36 276 
Thailand 62 193 


10 
6 


14720 

28425 


12 
5 


16 115 
24810 


439 
456 


Timor-Leste 


739 18 


635 


10 315 


49 


Togo 


4801 


10 


2474 


12 


2675 


175 


Tonga 


103 


10 


70 


12 79 


2 


Trinidad and Tobago 


1 298 


15 


2 156 


10 1 253 


23 


Tunisia 


9728 


15 


12956 6 


4798 


I 298 


Turkey 


70318 


16 


102 552 


13 


62 782 


1 584 


Turkmenistan 


4794 


34 


11 671 


7 


2 182 


; 221 


Tuvalu 


10 


18 


11 


20 


11 





Uganda 


25004 


10 


10 163 


11 


11 043 


288 


Ukraine 


48 902 28 


335610 


13 


126 117 


3085 


United Arab Emirates 


2937 17 


2235 4 


363 


16 


United Kingdom 


59 068 7 


120530 4 


59322 


1 712 


United States of America 291038 


8 


514450 4 


163 768 


3 479 


Uruguay 


3391 


6 


3980 


7 


3 773 


32 


Uzbekistan 


25705 


24 


55693 


12 


23 436 


1 558 


Vanuatu 


207 


13 


120 


13 


122 


3 


Venezuela 


25226 


10 


17967 


5 


8 720 


208 


Viet Nam 


80278 


10 


66 179 


8 


58308 


4210 


Yemen 


19315 


22 


16217 9 


6464 


743 


Zambia 


10698 


8 


4 153 9 


4604 


135 


Zimbabwe 


12 835 


8 


5752 


10 


6264 


158 


90 







5 6 
Smoking prevalence Diabetes 

1'iTii'iitasje of people 18 IVrivntaiy <>l proplr 
M-ars aiul above \vlio smoke aged 20 years and alxwe 
-003 IT lau-it iiuJi/iiWi' Juta with di.ibrh-s 
w,,nu-n ^00 


7 
Research 

Number of publications 
on cardiovascular disease 
1991 2001 


8 
Policies and 
legislation 

Legal status of smoking 
in government buildings 
2004 or latest available data 


Country 


34.6% 


5.0% 6.2% 


restricted 


Saint Lucia 


34.6% 


5.6% 7.3% 


- 


unknown Saint Vincent and Grenadines 


67.4% 


28.8% 6.1o/o 


HHHHHHi 


banned 


Samoa 


- 


- , 9.2o/o 


- 


unknown 


San Marino 


m 


0.90/o 


HHHHHMHI 


not regulated 


Sao Tome and Principe 


29.1% 


1.20/0 9.3o/o 51 


banned Saudi Arabia 


21.2% 


1.50/o 3.4o/o 


3 


not regulated Senegal 


55.5% 


51 .80/0 4.20/o 


21 


not regulated 


Serbia ft Montenegro 


32.5% 


15.00/0 14.6o/o 


HBHBHMH93 


unknown 


Seychelles 


- 


3.3% 


- 


unknown 


Sierra Leone 


23.7% 


3.2% 11.40/0 


76 


restricted 


Singapore 


42.3% 


28.00/0 3.9% 


25 


banned 


Slovakia 


32.7% 


20.80/0 4.30/o 


34 


restricted 


Slovenia 


- 


- 


6.40/0 


- 


restricted 


Solomon Islands 


HUH 


- 


2.70/0 


HBHHHBHi 


unknown 


Somalia 


43.4% 


13.9% 3.40/o 


77 


restricted 


South Africa 


43.9% 


31.20/0 8.70/0 689 


restricted 


Spain 


38.7% 


3.1% 5.4o/o 6 


banned 


Sri Lanka 


27.7% 


2.7% 2.9o/o 


- 


restricted 


Sudan 


- 


- j 3.8% 


- 


not regulated 


Suriname 


19.6% 


4.9o/o 2.9o/o 


HBHHHHI 


not regulated 


Swaziland 


21.3% 
37.6% 


24.90/0 
28.3% 


4.3% 
3.9% 


654 
440 


banned 
restricted 


Sweden 
Switzerland 


44.0% 


16.70/0 


8.20/0 


banned 


Syrian Arab Republic 


IHH 


HHBSHI 


3.1o/o 


- 


not regulated 


Tajikistan 


48.9% 


7.20/o 


1 .30/0 


_ 


not regulated 


Tanzania, United Republic of 


32.2% 


2.7o/o 


3.80/o 


59 


restricted 


Thailand 


- 


- 


- 


- 


unknown 


Timor-Leste 


Bin 


HHMI 


3.1% 


* 


not regulated 


Togo 


62.10/0 


14.20/0 i 6.30/0 


- 


banned 


Tonga 


- 


- 


7.30/o 


5 


not regulated 


Trinidad and Tobago 


52.90/0 


2.50/o 


2.90/o 


8 


restricted 


Tunisia 


51.10/0 


18.50/0 


7.30/o 


578 


banned 


Turkey 


- 


- 


3.20/o 


- 


banned 


Turkmenistan 


BBH 


- 


6.3% 


HHHHHHi! 


banned 


Tuvalu 


33.40/0 


7.1o/o 


1.1% 


2 


restricted 


Uganda 


55.5% 


14.70/0 


4.40/o 


19 


restricted 


Ukraine 


27.6% 


4.00/0 


20.5o/o 


8 


restricted United Arab Emirates 


34.60/0 


34.40/0 3.90/o 


2 667 


not regulated 


United Kingdom 


27.80/0 


22.3% 8.80/0 


12 502 


restricted 


United States of America 


39.40/0 


30.80/0 6.80/o 


2 


restricted 


Uruguay 


28.70/0 


1 .40/o 3.20/o 1 


not regulated 


Uzbekistan 


47.90/0 


4.80/o 6.9% 


restricted 


Vanuatu 


51.90/0 


20.5o/o 4.3% unknown 


Venezuela 


53.2% 


3.0% 


1.80/o 


banned 


Viet Nam 


60.00/0 


29.0o/o 


4.40/o 


unknown 


Yemen 


21.40/0 


8.8% 


1 .6% 


restricted 


Zambia 


32.2o/o 


4.6o/o 


2-QO/o 2 


unknown Zimbabwe 




91 



Glossary of terms used in this publication 



ACE inhibitors: angiotensin-converting-enzyme 
inhibitors. Drugs used to treat high blood pressure, and 
to aid healing after a heart attack. 

Angina (angina pectoris): pain or discomfort in the 
chest that occurs when part of the heart does not 
receive enough blood. Typically, it is precipitated by 
effort and relieved by rest. 

Angioplasty: a non-invasive surgical procedure used 
to open up blockages in blood vessels, particularly the 
coronary arteries that feed the heart. Often performed 
with either a balloon or a wire mesh (stent). 

Anticoagulant: medication that delays the clotting 
(coagulation) of blood. 

Arrhythmia: a change in the regular beat or rhythm of 
the heart. The heart may seem to skip a beat, or beat 
irregularly, or beat very fast or very slowly. 

Arteriosclerosis: a general term for the hardening of 
the arteries. 

Asymptomatic: without symptoms. This term may 
apply either to healthy persons or to persons with 
preclinical (prior to clinical diagnosis) disease in whom 
symptoms are not yet apparent. 

Atherosclerosis: one form of arteriosclerosis, where 
the hardening and narrowing of the arteries is caused by 
the slow build-up of fatty deposits on the inside lining. 

Atrial fibrillation: a common heart rhythm disorder 
in which the two small upper chambers of the heart 
(the atria) quiver instead of beating effectively. This 
quivering makes the heart less efficient, allows blood to 
pool and form clots, and predisposes to stroke. 

Blood pressure: the force of the blood pushing 
against the walls of arteries. Blood pressure is given as 
two numbers: systolic pressure (the pressure while the 
heart is contracting) and diastolic pressure (the pressure 
when the heart is resting between contractions). 

Body mass index (BMI): a measure of weight in 
relation to height. It is calculated as weight (in 
kilograms) divided by the square of height (in metres). 
A BMI of less than 25 is considered normal, 25-30 is 
overweight, and greater than 30 defines obesity. 

Cardiovascular disease (CVD): any disease of the 
heart or blood vessels, including stroke and high blood 

o o 

pressure. 



Carotid stenosis: narrowing of the carotid arteries, 

O 

the main arteries in the neck that supply blood to the 
brain. 

Cerebrovascular disease: also called a stroke or the 
brain equivalent of a heart attack. A condition in which a 
blood vessel in the brain bursts or is clogged bv a blood 

oo 7 

clot, leading to inadequate blood supply to the brain and 
death of brain cells. 

Cholesterol: a waxy substance that circulates in the 
bloodstream. 

Cholesterol plaques: deposits of fat, cholesterol, 
cellular waste products, calcium and other substances 
that build up on the inner lining of an arterv. 

1 O J 

Congestive heart failure: a condition in which the 
heart cannot pump enough blood to meet the needs of 
the body's other organs. 

Coronary artery bypass surgery (CABG): A type 
of heart surgery that re-routes blood around clogged 
arteries or "bypasses" them - to improve the supply of 
blood and oxygen to the heart. 

Coronary heart disease: heart disease in which the 
coronary arteries are narrowed and the supply of blood 
and oxygen to the heart therefore decreased. Also 
called coronary artery disease or ischaemic heart 
disease. It includes heart attack and angina. 

o 

Developing country, high mortality: a developing 
country with high child mortality and high or very high 
adult mortality. 

Developing country, low mortality: a developing 
country with low child mortality and low adult 
mortality. 

Diabetes mellitus: a chronic disease due to either 
insulin deficiency or resistance to insulin action or both, 
and associated with hyperglycaemia (elevated blood 
glucose levels). 

Direct costs: costs associated with an illness that can 
be attributed to a medical service, procedure, 
medication, etc., such as X-ray examination, 
pharmaceutical drugs (for example, insulin), surgery, or 
a clinic visit. 

Disability adjusted life years (DALYs): a measure 
of overall burden of a disease by combining the years of 
potential life lost due to premature death and the years 
of productive life lost due to the disability. One DALY 
is one lost year of healthy life. 



92 



Epidemic: tin- occurrence 1 in a community or region of 
cases ol an illness, specific health-related behaviour, or 
other health-related events clearly in excess of what 
would normally be expected. 

Health: a state of complete physical, mental, and social 
\u-ll being and not merely the absence of disease or 
infirmity. 

HDL (high-density lipoprotein) cholesterol: the 

so-called "yood cholesterol". HDL helps remove 
cholesterol from the blood vessels. High levels of blood 
HDL protect against heart disease. 

Heart attack (myocardial infarction): death of 
part ol the heart muscle as a result of a coronary artery 
becoming completely blocked, usually by a blood clot 
(thrombus), resulting in lack of blood flow to the heart 
muscle and therefore loss of needed oxygen. 

Heart failure: see Congestive heart failure. 

High blood pressure: a systolic blood pressure of 
140 mmHg or greater or a diastolic pressure of 90 
mmHg or greater. 

Homocysteine: an amino acid produced by the body. 
Elevated levels of homocvsteine in the blood can 
damage blood vessels and disrupt normal blood 
clotting, and possibly increase the risk of heart attack, 
stroke, and peripheral vascular disease. 

Indirect costs: costs associated with an illness that 
occur because an individual or familv members cannot 
work at their usual jobs, because of premature death, 
sickness, or disability. 

Ischaemic heart disease: see Coronary heart 
disease. 

LDL (low-density lipoprotein) cholesterol: the 

so-called "bad cholesterol". High levels of LDL put 
people at risk of heart attack. 

Lipid: fat or fat-like substance, such as cholesterol, 
present in blood and body tissues. 

MET: metabolic equivalent; a measure of energy 
expenditure. One MET/min is the amount of energy 
expended while sitting quietly at rest for one minute. 

Obesity: a condition characterized by excessive body 
fat. Usually defined as a body mass index greater than 
30. 

Peripheral vascular disease: disease of certain 
blood vessels outside the heart or disease of the lymph 
vessels, for example the arteries supplying the limbs, 
which leads to inadequate blood supply and claudication 
(intermittent pain on exercise such as walking). 



Physical activity: bodily movement that substantially 
increases energy expenditure. 

Premature death: death that occurs at an age earlier 
than the average life expectancy for the population. 

Primary prevention: a strategy that helps to prevent 
the onset of a disease or condition in people who are at 
risk but do not already have the disease or condition. 
Examples are promotion of exercise in the general 
population, smoking prevention in young people, and 
also the treatment and control of high blood pressure as 
a strategy for primary prevention of stroke. 

Rheumatic heart disease: damage to the heart 
valves and other heart structures from inflammation and 
scarring caused by rheumatic fever. Rheumatic fever 
begins with a sore throat due to streptococcal infection. 

Secondary prevention: a strategy that helps to 
prevent recurrent disease or complications in people 
who already have the disease. For example, the use of a 
daily dose of aspirin by heart attack survivors is an 
effective strategy for preventing a second heart attack. 

Sedentary: denotes a person who is relatively inactive 
and has a lifestyle characterized by a lot of sitting. 

Stent: a device used to support tissues while healing 
takes place. A stent can keep "tube-shaped" structures, 
such as blood vessels, open after a surgical procedure. 
Anintraluminal coronary artery stent is a small, self- 
expanding, stainless steel mesh tube, which is placed 
within a coronary artery to keep the vessel open. 

Stroke: the brain equivalent of a heart attack. 
A condition in which a blood vessel in the brain bursts 
(haemorrhagic stroke) or is clogged (embolic or 
ischaemic stroke) by a blood clot. This leads to 
inadequate blood supply to the brain and death of the 
brain cells, and usually results in temporary or 
permanent neurological deficits. 

Transient ischaemic attack (TIA): small stroke-like 
event, which resolves in a day or less. It is often a 
warning sign of an impending stroke. 

Triglyceride: the chemical form in which most fat 
exists in food and in the body. 



93 



Sources 



PART 1 CARDIOVASCULAR 
DISEASE 

1 Types of cardiovascular disease 

Deaths from cardiovascular diseases 

Mortality and burden of disease estimates for 
countries provided by Colin Mathers (Evidence and 
Information for Policy, WHO) from analyses 
prepared for The World Health Report 2003. 

Global deaths from CVD 

World Health Organization. The World Health Report 
2003: shaping the future. Geneva, WHO, 2003, 
Annex Table 2:156. 

Clipboard 

WHO. The World Health Report 2003: shaping the 
future. Geneva, WHO, 2003, Annex Table 2:156. 

2 Rheumatic fever and rheumatic 
heart disease 

Map: Deaths from rheumatic heart disease 

Mortality and burden of disease estimates for 
countries provided by Colin Mathers (Evidence and 
Information for Policy, WHO) from analyses 
prepared for The World Health Report 2003. 

Rheumatic heart disease in children 

Carapetis JR. The current evidence for the burden of 
group A streptococcal diseases. A review of WHO 
activities in, the burden of, and the evidence for strategies 
to control group A streptococcal diseases. Geneva, 
WHO, 2004. 

Deaths from rheumatic fever and rheumatic 
heart disease in the Aboriginal and non- 
Aboriginal populations of Australia 

Carapetis JR, Currie BJ. Mortality due to acute 
rheumatic fever and rheumatic heart disease in the 
Northern Territory: a preventable cause of death in 
Aboriginal people. Australian and New Zealand journal 
of public health, 1999, 23:159-163. 



Clipboard 

Rheumaticfever and rheumatic heart disease: report of a 
WHO Expert Committee. Geneva, WHO, 2003 (WHO 
Technical Report Series, No. 923). 

Text 

Stollerman GH. Rheumatic fever in the 21st century. 
Clinics in infectious diseases, 2001 , 33:806814. 

Treating acute rheumatic fever. British medical journal, 
2003, 327:631 63 (editorial). 

WHO. The World Health Report 2003: shaping the 
future. Geneva, WHO, 2003, Annex Table 2:156. 

Veasy LG, Hill HR. Immunologic and clinical 
correlations in rheumatic fever and rheumatic heart 
disease. Pediatric infectious diseases journal, 1997, 
16:400^1-07. 

PART 2 RISK FACTORS 

3 Risk factors 

Leading risk factors 

WHO. Leading 10 selected risk factors as percentage 
cause of disease burden measured in DALYs. The 
World Health Report 2002: reducing risks, promoting 
healthy life. Geneva, WHO, 2002, 162. 

Contributory factors 

WHO. Quantifying selected major risks to health. 
The World Health Report 2002: reducing risks, promoting 
healthy life. Geneva, WHO, 2002, 57-61. 

Clipboard 

Beaglehole R, Magnus P. The search for new risk 
factors for coronary heart disease: occupational therapy 
for epidemiologists? International journal of epidemiology , 
2002, 3 1(6): 11 17 22; author reply 1134-5. 

Text 

Inter-Society Commission for Heart Disease 
Resources A: Primary prevention of the 
atherosclerotic diseases. Circulation, 1970, 
42:A55-A95. 



94 



4 Risk factors start in childhood and 
youth 

Maps: Early starters; Clipboard 

Global Youth Collaborating Group. Special report: 
Differences in worldwide tobacco use by gender: 
findings from the Global Youth Tobacco Survey. 
Journal of school health, 2003, 73(6):207 21 5. 
Detailed country information available at: 
http://www.cdc.gov/tobacco/global/GYTS.htm 

Overweight trends in the USA 

CDC, National Center for Health Statistics. Health, 
United States, 2003 with Chartbook on trends in the 
health of Americans. Hyattsville, MD, 2003. BMI at 
or above the sex-age-specific 95th percentile 
http://www.cdc.gov/nchs/data/hus/tables/2003/ 
03hus069.pdf 

Overweight youth 

Lissau I, Overpeck MD, Ruan WJ, Due P, Holstein 
BE, Hedinger M, and the Health Behaviour in 

o 

School-aged Children Working Group. Body mass 
index and overweight in adolescents in 1 3 European 
countries, Israel, and the United States. Archives of 
pediatric and adolescent medicine, 2004, 158:2733. 
Table 3. Prevalence of BMI at or above the 95th 
percentile (overweight) by sex (self-reported). 

Wow: USA 

Kimm SYS et al. Decline in physical activity in black 
girls and white girls during adolescence. New England 
journal of medicine, 2002, 347:709-15. 

Clipboard 

Overweight: WHO Fact Sheet, Global Strategy on 
Diet, Physical Activity and Health. Obesity and 
overweight. Geneva, WHO, 2003 

o 

http://www.who.int/hpr/gs.facts.shtml 

Text 

Zimmet P. The burden of type 2 diabetes: are we 
doing enough? Diabetes and metabolism, 2003, 
29(4Pt2):6S9-6S18. 

Kitagawa T, Owada M, Urakami T, Yamauchi K. 
Increased incidence of non-insulin dependent diabetes 
mellitus among Japanese schoolchildren correlates 
with an increased intake of animal protein and fat. 
Clinical pediatrics (Philadelphia), 1 998, 37(2): 111115. 



Likitmaskul S, Kiattisathavee P, Chaichanwatanakul 
K, Punnakanta L, Angsusingha K, Tuchinda C. 
Increasing prevalence of type 2 diabetes mellitus in 
Thai children and adolescents associated with 
increasing prevalence of obesity. Journal of pediatric 
endocrinology and metabolism, 2003, 16(l):71-77. 

Berenson GS, Srinivasan SR, Bao W, Newman WP 
3rd, Tracy RE, Wattigney WA. Association between 
multiple cardiovascular risk factors and 
atherosclerosis in children and young adults. The 
Bogalusa Heart Study. New England journal of medicine, 
1998, 338(23):1650-1656. 

5 Risk factor: blood pressure 

Maps: Blood Pressure 

WHO Global NCD InfoBase [online database]. 

Geneva, WHO, 2004 

http : / / www. who. int /ncd_sur veillance / infobase / 

High blood pressure in the USA 

Trends, USA, 1960-2000; Health, United States 
2002; Table 68. Hypertension among persons 20 
years of age and over, according to sex, age, race, 
and Hispanic origin: United States, 
1960-62,1971-74, 1976-80, 1988-94, and 
1999-2000. Referencing Centers for Disease 
Control and Prevention, National Center for Health 
Statistics, National Health and Nutrition Examination 
Survey, Hispanic Health and Nutrition Examination 
Survey (1982-84), and National Health Examination 
Survey (1960-62) 
http://www.cdc.gov/nchs/data/hus/hus02.pdf 

Blood pressure changes with age in the 
Gambia 

van der Sande MA, Bailey R, Faal H et al. 
Nationwide prevalence study of hypertension and 
related non-communicable diseases in The Gambia. 

Tropical medicine and international health, 1997, 
2(11):1039-1048. 

Blood pressure in India 

Singh RB, Suh IL, Singh V. et al. Hypertension and 
stroke in Asia: prevalence, control and strategies in 
developing countries for prevention. Journal of human 
hypertension, 2000, 14:749-763. 



95 



High blood pressure by years of education in 
South Africa 

South Africa Demographic and Health Survey 1 998 
http://www.doh.gov.za/facts/1998/sadhs98/ 

Text 

Vasan RS, Larson MG, Leip EP, Evans JC, O'Donncll 
CJ, Kannel WB, Levy D. Impact of high-normal 
blood pressure on the risk of cardiovascular disease. 
New England journal of medicine, 2001 , 
345:1291 1297. 

World Hypertension League. The high blood 
pressure /heart failure link: a new concern for older 
Americans 
http://www.mco.edu/org/whl/hrtfail.html 

Huxley R, Neil A, Collins R. Unravelling the fetal 
origins hypothesis: is there really an inverse 
association between birthweight and subsequent 
blood pressure? Lancet, 2002, 360:659-665. 

Systolic blood pressure. British medical journal, 2002, 
325:917-918 (editorial). 

Sleight P. Fact sheet: isolated hypertension (ISH). 
World Hypertension League 
http://www.mco.edu/org/whl/isyshype.html 

Weinberger MH, Miller JZ, Luft FC, Grim CE, 
Fineberg NS. Definitions and characteristics of 

o 

sodium sensitivity and blood pressure resistance. 
Hypertension, 1986, 8(2): 1 27-1 34. 

He J, Ogden LG, Vupputuri S, Bazzano LA, Loria C, 
Whelton PK. Dietary sodium intake and subsequent 
risk of cardiovascular disease in overweight adults. 

o 

Journal of the American Medical Association, 1999, 
282:2027-2034. 



6 Risk factor: lipids 

Map: Cholesterol 

WHO Global NCD InfoBase [online database]. 

Geneva, WHO 

http : / / www. who. int / ncd_sur veillance / infobase / 



Current recommended lipid levels 

De Backer G, Ambrosioni E, Borch-Johnsen K et al.; 
Third Joint Force of European and other Societies on 
Cardiovascular Disease and Prevention in Clinical 
Practice. European guidelines on cardiovascular 
disease prevention in clinical practice. Atherosclerosis, 
2003, 171(1):145-155. 

Third Report of the National Cholesterol Education 

Program (NCEP) Expert Panel on Detection, 

Evaluation, and Treatment of High Blood Cholesterol 

in Adults (Adult Treatment Panel III) final report. 

Circulation, 2002, 106:3143-3421 

http: / /circ. ahajournals.org/cgi /reprint/ 1 06/2 5 / 

3143.pdf 

Trends in cholesterol levels in Beijing, China 

Tolonen H, Kuulasmaa K, Ruokokoski. MONICA 
population survey data book. 2000 (data from 
1984 1993). Zhao Dong, personal communication 
(data from 1996-1999). 

Wow: USA 

American Heart Foundation. About cholesterol 
http: / / www.americanheart.org/presenter.jhtml? 
identified 185 

Clipboard 

WHO. The World Health Report 2002: reducing risks, 
promoting healthy life. Geneva, WHO, 2002. 

Text 

American Heart Foundation. About cholesterol 
http://www.americanheart.org/ 

7 Risk factor: tobacco 

Maps: Smoking prevalence 

WHO Global NCD InfoBase [online database]. 

Geneva, WHO 

http: //www. who. int/ncd_surveillance/infobase/ 

Cardiovascular risks of smoking 

Price JF, Mowbray PI, Lee AJ, Rumley A, Lowe GD, 
Fowkes FG. Smoking and cardiovascular risk factors 

o 

in the development of cardiovascular disease and 
coronary artery disease: Edinburgh Artery Study. 

European heart journal, 1999, 20:344-353. 



96 



Prescott E, Hippe M, Schnohr P, Hein HO, Vestbo J. 
Smoking and risk of myocardial infarction in women 
and men: longitudinal population study. British 
medical journal, 1998, 316:1043 104?" 

Smoking and stroke: a causative role. Heavy smokers 
with hypertension benefit most from stopping. British 
medical journal, 1998, 317:962-963 (editorial). 

Cole CW, Hill GB, Farzad E, Bouchard A, Moher D, 
Rody K, Shea B. Cigarette smoking and peripheral 
arterial occlusive disease. Surgery, 1993, 
1 14(4):75 3-756; discussion, 756-757. 

Lederlc FA, Johnson GR, Wilson SE et al. 
Prevalence and associations of abdominal aortic 
aneurysm detected through screening. Aneurysm 
Detection and Management (ADAM) Veterans Affairs 
Cooperative Study Group. Annals of internal medicine, 
1997, 1 26(6) :44 1-449. 

Smoking and urology: male fertility and sexuality 
dysfunctions. Cigarettes: what the warning label doesn't tell 
you: the first comprehensive guide to the health consequences 
of smoking. New York. The American Council on 
Science and Health, 1996, Chapter 1 1:95-100. 

Smoking harms men. Sydney Morning Herald, 24 
March 1997, 3 (quoting Australian and New Zealand 
journal of medicine). 

Cardiovascular risks of passive smoking 

Panagiotakos DB, Pitsavos C, Chrysohoou C, 
Skoumas J, Masoura C, Toutouzas P, Stefanadis C. 
Effect of exposure to secondhand smoke on markers 
of inflammation: the ATTICA study. American journal 
of medicine, 2004, 1 16(3):145-150. 

Bonita R, Duncan J, Truelsen T, Jackson RT, 
Beaglehole R. Passive smoking as well as active 

o o 

smoking increases the risk of stroke. Tobacco control, 
1999, 8:156-161. 

International Consultation on Environmental Tobacco 
Smoke (ETS) and Child Health, 11-14 January 1999. 
Geneva, WHO, 1999 (WHO/NCD/TFI//99.10). 



Smokers don't know the risks of heart attack 

Ayanian JZ, Cleary PD. Perceived risks of heart 
disease and cancer among cigarette smokers. Journal of 
the American Medical Association, 1999, 281 : 101 9-102 1 . 

Wow: USA 

National Cancer Institute. Health ejfects of exposure to 
environmental tobacco smoke: the report of the California 
Environmental Protection Agency. Bethesda, MD, US 
Department of Health and Human Services, National 
Institutes of Health, National Cancer Institute, 1999 
(Smoking and Tobacco Control Monograph no. 10; 
NIH Pub. No. 99-4-645). 

Wow: China 

Smoking and health in China. 1996 National Prevalence 

o 

Survey of Smoking Pattern. Beijing, China Science and 
Technology Press, undated, 89. 

Cv 

Text 

English IP, Willius FA, Berkson I. Tobacco and 

o J ' J 

coronary disease. Journal of the American Medical 
Association, 1940, 115:1327-1329. 

Smoking study reveals grim disease risks. Australian 

Associated Press, 20 May 2002 

http:/ /news, ninemsn. com. au/Health/story_3 1927. 

asp?MSID=6d40353f6b864cd7806381801f7fdcOa 

Bonita R, Duncan J, Truelsen T, Jackson RT, 
Beaglehole R. Passive smoking as well as active 
smoking increases the risk of acute stroke. Tobacco 
control, 1999,8:156-160. 

Lehr HA, Weyrich AS, Saetzle RK et al. Vitamin C 
blocks inflammatory platelet-activating factor 
mimetics created by cigarette smoking. Journal of 
clinical investigation, 1997, 99(10):2358-2364. 

Davis JW, Shelton L, Watanabe IS, Arnold J. Passive 
smoking affects endothelium and platelets. Archives of 
internal medicine, 1989, 149(2):386-389. 

McBride PE. The health consequences of smoking: 
cardivascular disease. Medical clinics of North America, 
1992,76:333-353. 

Aronow W. Effect of passive smoking on angina 
pectoris. New England journal of medicine, 1978, 
299:21-24. 



97 



Humphries SE, Talmud PJ, Hawc E, Bolla M, Day 
INM, Miller GJ. Apolipoprotein E4 and coronary 
heart disease in middle-aged men who smoke- a 

o 

prospective study. Lancet, 2001, 358:1 15-1 19. 

Gene linked to heart disease risk. BBC online, 1 3 July 2001 

http: / 7www.bbc.co.uk 

Prescott E, Scharling H, Osier M, Schnohr P. 
Importance of light smoking and inhalation habits on 
risk of myocardial infarction and all cause mortality. 
A 22 year follow up of 12 149 men and women in 
The Copenhagen City Heart Study. Journal of 
epidemiology and community health, 2002, 56:702706 
http://jech.bmjjournals.com/cgi/content/abstract/ 
56/9/702 

Willett WC, Green A, Stampfer MJ et al. Relative 
and absolute excess risks of coronary heart disease 
among women who smoke cigarettes. New England 
journal of medicine, 1987, 317:1303-1309. 

8 Risk factor: physical inactivity 

Map: Physical activity levels 
Non-EU countries 

Unpublished preliminary analysis of the World 
Health Survey 2002-2003. Geneva, WHO. 

Riitten A et al. Using different physical activity 
measurements in eight European countries. Results 
of the European Physical Activity Surveillance 
System (EUPASS) time series survey. Public health 
nutrition, 2003, 6(4): 371 376. 

World Health Survey. Eurobarometer: International 
Physical Activity Questionnaire (IPAQ). Geneva, WHO 
http : / / www. who. int / ncd_sur veillance / infobase / 

EU countries 

Riitten A, Abu- Omar K. Prevalence of physical 
activity in the European Union. Sozial- und 

Praventivmedizin/ Social and Preventative Medicine, 
2004, 49(4). 

World Health Survey. Eurobarometer: International 

Physical Activity Questionnaire (IPAQ). Geneva, 

WHO 

http : / / www. who. int / ncd_sur veillance / infobase / 



Sitting 

Rutten A et al. Using different physical activity 
measurements in eight European countries. Results 
of the European Physical Activity Surveillance 
System (EUPASS) time series survey. Public health 
nutrition, 2003, 6(4): 371-376. 

Physical activity 

Department of Health, Hong Kong. Fact sheet on 
physical activity 

http://www.info.gov.hk/dh/do_you_k/eng/ 
exercise.htm 

Physical inactivity by social class in India 

Singh RB, Sharma JP, Rastogi V, Niaz MA, Singh NK. 
Prevalence and determinants of hypertension in the 
Indian social class and heart survey. Journal oj human 
hypertension, 1997, 11:51-56. 

Singapore keeps moving 

National Health Survey 1998. Singapore, Epidemiology 
and Disease Control Department, Ministry of 
Health, 1998. 

Transport 

American Automobile Manufacturers Association 
(A AM A). Motor vehicle facts and figures 1996. 
Proceed with caution: growth in the global motor vehicle 
Jleet. Washington DC, World Resources Institute, 
1996,44^7 
http://www.wri.org/trends/autos2.html 

The global fleet 

American Automobile Manufacturers Association 
(AAMA). World motor vehicle data 1993; and 
Motor vehicle facts and figures 1996. Proceed with 
caution: growth in the global motor vehicle Jleet. 
Washington, DC, World Resources Institute, 1996 
http://www.wri.org/trends/autos2.html 

Wow: Being physically active...; Text 

Bull FC, Armstrong T, Dixon T, Ham S, Neiman A, 

o ' 

Pratt M. Physical inactivity. Ezzati M, Lopez A, 
Rodgers A, Murray C, eds. Comparative quantification 
oj health risks: global and regional burden of disease due to 
selected major riskfactors. Geneva, WHO, 2004 
(in press). 



98 



Wow: Worldwide, physical inactivity... 

The World Health Report 2002: reducing risks, promoting 
healthy life. Geneva, WHO, 2002:61. 

Wow: In 1997, in China... 

Matters of scale: November/ December 1997. 
Driving up CO 2 

http://www.worldwatch.org/pubs/mag/1997/106 
/mos/ 

Wow: 25% of the world's cars... 

Renner M. Live online discussions. Five hundred million 
cars, one planet Who's going to give? 8 August 2003 
http://www.worldwatch.org/live/discussion/83/ 

Text 

World Heart Federation. A global embrace for World 
Heart Day. Message from the President, 29 Sept 2002 
http : / / www. worldheartday. org/ WHDArchive / 
whd2002/ news/news. asp# 

Kujala UM, Kaprio J, Sarna S, Koskenvuo M. 
Relationship of leisure-time physical activity and 
mortality: the Finnish twin cohort. Journal of the 
American Medical Association, 1998, 279:440-444. 

HeartBytes. Reduce heart disease risk: encourage and 
prescribe exercise Jbr your patients. 
http://www.medscape.com/viewarticle/4701 15? 
mpid=25341 

Cervero R. Shapeless, spread out, skipped over and 
scattershot sprawl sweeps the globe. The World Paper, 
http : / / w w w. worldpaper. com / 2000 / mar 2 000 / 
cervero.html 



9 Risk factor: obesity 

Maps: Body mass index 

WHO Global NCD InfoBase [online database]. 

Geneva, WHO 

http: //www. who. int/ncd_surveillance/infobase/ 

Food consumption 

Diet, nutrition and the prevention of chronic diseases: 
report of a Joint WHO/FAO Expert Consultation. 
Geneva, WHO, 2003 (WHO Technical Report 
Series No. 916): Table 1:15. Data from: Popkin 
BM. The shift in stages of the nutritional transition 
in the developing world differs from past 



experiences! Public health nutrition, 2002, 
5:205-214. 

Apple shape at higher risk of CVD than pear 
shape 

Lakka HM, Lakka TA, Tuomilehto J, Salonen JT. 
Abdominal obesity is associated with increased risk of 
acute coronary events in men. European heart journal, 
2002,23:706-713 (cited in Sowers JR. Obesity as a 
cardiovascular risk factor. American journal cf medicine, 
2003, 115(8A):37S-4-lS). 

Isomaa B, Almgren P, Tuomi T, et al. Cardiovascular 
morbidity and mortality associated with the 
metabolic syndrome. Diabetes care, 2001, 
24:683-689 (cited in Sowers JR. Obesity as a 
cardiovascular risk factor. American journal of medicine, 

2003, 11S(8A): 375-^1 S). 

Overweight and obesity: defining overweight and obesity 
http: / /www. cdc.gov/nccdphp/dnpa/obesity/ 
defining.htm 

Wow: Thailand 

Associated Press in Bangkok. Thailand: Chubby 
nights soothe the heavyweight clubbers. South China 
Morning Post, 12 September 2002, 1 1 . 

Text 

WHO expert consultation. Appropriate body-mass 
index for Asian populations and its implications for 
policy and intervention strategies. Lancet, 2004, 
363:157 63. 

Eckel RH, Krauss RM. American Heart Association 
call to action: obesity as a major risk factor for 
coronary heart disease. Circulation, 1998, 
97:2099-2100. 

WHO. The World Health Report 2002: reducing risks, 
promoting healthy life. Geneva, WHO, 2002. 

Peeters A, Barendregt JJ, Willekens F, Mackenbach 
JP, Mamun AA, Bonneux L. Obesity in adulthood 
and its consequences for life expectancy: a life table 
analysis. Annals of internal medicine, 2003, 
138:24-32. 

The catastrophic failures of public health. Lancet, 

2004, 363(9411): 157-63 (editorial)). 



99 



Buncombe A. American undertakers offer 
'super-size' coffins as population piles on the pounds. 
The Independent, 29 September 2003 
http : / / news . independent .co.uk/ world / amer icas / 
story.jsp?story =448034 

Fast food takeaways China. BBC online, 1999 
http: / /news. bbc.co.uk/hi/english/health/ 
newsid_364000/364273.stm 

Easen N. Asia Jails foul tojat. CNN, 21 Feb 2002 
http://www.cnn.com/2002/WORLD/asiapcf/ 
auspac / 02 / 2 1 / asia . obesity / Prelated 

Associated Press. New Zealand. Boarding pass and 
scales, please NZ weighs the trend for heavier passenger 
loads. South China Morning Post, 4 October 2003, 
A10. 



10 Risk factor: diabetes 

Map: Prevalence of diabetes; Diabetes 
prevalence and trends; Clipboard 

Wild S, Roglic G, Green A, Sicree R, King H. 
Global prevalence of diabetes. Estimates for the year 
2000 and projections for 2030. Diabetes care, 2004, 
27:1047-1053. 

Text 

International Diabetes Federation 

http:// www.idf.org/home/index.cfmPnode =2 64 

1 1 Risk factor: socioeconomic status 

Prevalence of CVD risk factors by education 
in Canada 

Choiniere R, Lafontaine P, Edwards AC. Distribution 
of cardiovascular disease risk factors by 
socioeconomic status among Canadian adults. 

o 

Canadian Medical Association journal, 2000, 162(9 
Suppl):S13 24. Note: Definitions used: Physical 
inactivity: leisure exercise less than once per week 
during previous month. Elevated cholesterol: >5.2 
mmol/1 after fasting 8 hours or more. 

The CVD mortality gap in the USA 

Singh GK, Siahpush M. Increasing inequalities in all- 
cause and cardiovascular mortality among US adults 
aged 2564 years by area and socioeconomic status, 



19691998. International journal of epidemiology , 
2002, 31(3):600 613. 

Prevalence of high blood pressure by income 
in Trinidad and Tobago 

Gulliford MC, Mahabir D, Rocke B. Socioeconomic 
inequality in blood pressure and its determinants: 
cross- sectional data from Trinidad and Tobago. 
Journal of human hypertension, 2004, 18:6170. 

Education level and obesity in Italy 

Giampaoli S, Palmieri L, Dima F, Pilotto L, Vescio 
MF, Vanuzzo D. Socioeconomic aspects and 
cardiovascular risk factors: experience at the 
Cardiovascular Epidemiologic Observatory. Italian 
heart journal, 2001, 2(3 Suppl): 294-302. 

Smoking and occupation in Uganda 

Uganda Demographic and Health Survey 20002001 . 

Smoking by years of education in South Africa 

South Africa Demographic and Health Survey 
(SADHS) 1998. 

Income and obesity in Saudi Arabia 

Al-Nuaim AA et al. Overweight and obesity in Saudi 
Arabian adult population, role of socio-demographic 
variables. Journal of community health, 1997, 
22(3):211-23. 

Prevalence of diabetes by income in India 

Ramachandran A, Snehalatha C, Kapur A et al. 
Diabetes Epidemiology Study Group in India (DESI). 
High prevalence of diabetes and impaired glucose 
tolerance in India: National Urban Diabetes Survey. 
Diahetologia, 2001, 44(9): 1094-101 . 

Wow: Canada 

Evenson B. When rich and poor kids eat the same 
diet, poor ones get fatter. ProCOR, 12 September 
2003. 

Clipboard 

Steptoe A, Feldman PJ, Kunz S, Owen N, Willemsen 
G, Marmot M. Stress responsivity and socioeconomic 
status: a mechanism for increased cardiovascular 
disease risk? European heart journal, 2002, 
23(22): 1757-63. 



100 



Text 

Terris M. The development and prevention of 
cardiovascular disease risk factors: 
socioenvironmental influences. Preventive medicine, 
1999, 29(6 Pt2):Sl 1-17. 

Pickering T. Cardiovascular pathways: socioeconomic 
status and stress effects on hypertension and 
cardiovascular function. Annals of the New York 
Academy of Sciences, 1999, 896:262 277. 

Rao SV, Kaul P, Newby K et al. Poverty, process of 
care, and outcome in acute coronary syndrome. 
Journal of the American College of Cardiology , 2003, 
41:1948-54. 



12 Women: a special case? 

Smoking 

Prescott E, Hippe M, Schnohr P, Hein HO, Vestbo J. 
Smoking and risk of myocardial infarction in women 
and men: longitudinal population study. British 
medical journal, 1998, 316:1043-1047. 

No time to walk 

Clark J. News roundup: Women too busy to 
exercise. British medical journal, 2003, 326:467. 

Walking reduces coronary heart disease 

Lee IM, Rexrode KM, Cook NR, Manson JE, Buring 
JE. Physical activity and coronary heart disease in 
women. Is "no pain, no gain" passe? Journal of the 
American Medical Association, 2001, 285:1447-1454. 

Hormone replacement therapy 

Trevisan MM. Hormone replacement therapy. Global 
Symposium on Cardiovascular Prevention, Marbella, Spain, 
11-13 April 2003. 

Clipboard 

WHO. The World Health Report 2003: Shaping the 
future. Geneva, WHO, 2003: Annex Table 2. 

Text 

Kmietowicz Z. News roundup: Women fail to 
recognise risk of heart disease. British medical journal, 
2003, 326:355. 



Ulmer H, Kelleher C, Diem G, Concin H. Why Eve 
is not Adam: prospective follow-up in 149650 
women and men of cholesterol and other risk factors 
related to cardiovascular and all-cause mortality. 
Journal of women's health (Larchmount), 2004, 



Lerner DJ, Kannel WB. Patterns of coronary heart 
disease morbidity and mortality in the sexes: a 26- 
year follow-up of the Framingham population. 
American heart journal, 1986, 111:383-390. 

McKinlay JB. Some contributions from the social 
system to gender inequalities in heart disease. Journal 
of health and social behaviour, 1996, 37:1-26. 

Giles WH, Anda RF, Casper ML, Escobedo LG, 
Taylor HA. Race and sex differences in rates of 
invasive cardiac procedures in US hospitals: data 
from the National Hospital Discharge Survey. 
Archives of internal medicine, 1995, 155:318-324. 

Dustan HP. Coronary artery disease in women. 
Canadian journal of cardiology, 1 990, 
6(SupplB):19B-21B. 

LeKmann JB, Wehner PS, Lehmann CU, Savory LM. 
Gender bias in the evaluation of chest pain in the 
emergency department. American journal of cardiology , 
1996,77:641-644. 

Roquer J, Campello AR, Gomis M. Sex differences 
in first-ever acute stroke. Stroke, 2003, 
34(7): 158 1-1 585. 

Adams KF Jr, Sueta CA, Gheorghiade M, O'Connor 
CM, Schwartz TA, Koch GG, Uretsky B, Swedberg 
K, McKenna W, Soler-Soler J, Califf RM. Gender 
differences in survival in advanced heart failure. 
Insights from the FIRST study. Circulation, 1999, 
99(14): 1816-1821. 

Mosca L et al. Evidence-based guidelines for 
cardiovascular disease prevention in women. 
Circulation, 2004, 109:672-693. 



101 



PART 3 THE BURDEN 

13 Global burden of coronary heart 
disease 

Map: Healthy years of life lost to coronary 
heart disease 

Mortality and burden of disease estimates for 
countries provided by Colin Mathers (Evidence and 
Information for Policy, WHO) from analyses 
prepared for The World Health Report 2003. 

Disease burden in men; in women 

WHO. The World Health Report 2003: Shaping the 
future. Geneva, WHO, 2003. 

Clipboard; Text 

Ounpuu S, Anand S, Yusuf S. The global burden of 
cardiovascular disease. Medscape cardiology, 
24 January 2002 

http://www.medscape.com/viewarticle/420877PWe 
bLogicSession=Pj4P2wsr611rYWKbLSDskpUMbsjmJ 
xtWvxSNaGHCVd2ranocYJpC 1 42976445789882471 
33/1 84161 393/6/7001/7001/7002/7002/7001 /-I 

Text 

Nayha S. Cold and the risk of cardiovascular diseases. 
A review. International journal ofcircumpolar health, 
2002,61(4):373-380. 

14 Deaths from coronary heart 
disease 

Map: Deaths from coronary heart disease 

Mortality and burden of disease estimates for 
countries provided by Colin Mathers (Evidence and 
Information for Policy, WHO) from analyses 
prepared for The World Health Report 2003. 

Deaths from coronary heart disease 
compared with other causes 

WHO. The World Health Report 2003: Shaping the 
Juture. Geneva, WHO, 2003, Table 1.3:17. 

Change of heart 

British Heart Foundation Statistics database. 
1. Mortality. Table 1.5 
http: // www.heartstats.org 



Wow: 3.8 million men... 

WHO. The World Health Report 2003: Shaping the 
future. Geneva, WHO, 2003, Annex Table 2:154-1 59. 

Text 

Ounpuu S, Anand S, Yusuf S. The global burden of 

cardiovascular disease. Medscape cardiology, 

24 January 2002 

http: // www.medscape.com/viewarticle/420877PWe 

bLogicSession=Pj4P2wsr6 1 1 rYWKbLSDskpUMbsjmJ 

xtWvxSNaGHCVd2ranocYJpC 1 42976445789882471 

33/1 84161 393/6/7001/7001/7002/7002/7001 /-I 

Khot UN, Khot MB, Bajzer CT et al. Prevalence of 
conventional risk factors in patients with coronary 
heart disease. Journal of the American Medical 
Association, 2003, 290:898-904. 

Chambless L, Keil U, Dobson A, Mahonen M, 
Kuulasmaa K, Rajakangas AM, Lowel H, Tunstall- 
Pedoe H. Population versus clinical view of case 
fatality from acute coronary heart disease: results 
from the WHO MONICA Project 1985-1990. 
Multinational MONItorinp of Trends and 

o 

Determinants in CArdiovascular Disease. Circulation, 
1997, 96(1 1):3849-59. 

15 Global burden of stroke 

Map: Healthy years of life lost to stroke 

Mortality and burden of disease estimates for 
countries provided by Colin Mathers (Evidence and 
Information for Policy, WHO) from analyses 
prepared for The World Health Report 2003. 

Stroke in young people 

Jacobs BS, Boden-Albala B, Lin IF, Sacco RL. Stroke 
in the young in the northern Manhattan stroke study. 
Stroke, 2002, 33(1 2):2789-93. 

Oral contraceptives 

Lidegaard 0, Kreiner S. Contraceptives and cerebral 
thrombosis: a five-year national case-control study. 
Contraception, 2002, 65:197-205. 

Wow: United Kingdom 

Wise J. News: New clinical guidelines for stroke 
published. British medical journal, 2000, 320:823. 



102 



Wow: Stroke burden, 2020 

Murray CJL, Lope/. AD. The global burden of disease. 
Boston, Harvard School of Public Health (for WHO 
and the World Bank), 1996, Table 17i:830. 

Clipboard 

Chobanian AV, Bakris GL, Black HR et al. The 
Seventh Report of the Joint National Committee on 
Prevention, Detection, Evaluation, and Treatment of 
High Blood Pressure: The JNC 7 Report. Journal of the 
American Medical Association, 2003, 289:2560-2572. 

Text 

McCarron P, Davey Smith G, Okasha M, McEwen J. 
Blood pressure in young adulthood and mortality 
from cardiovascular disease. Lancet, 2000, 
355:1430-31. 

Adams RJ, McKie VC, Brambilla D et al. Stroke 
prevention trial in sickle cell anemia. Control clinical 
trials, New England journal of medicine, 1998, 
19:110 129. 

Bonita R, Scragg R, Stewart A, Jackson R, 
Beaglehole R. Cigarette smoking and risk of 
premature stroke in men and women. British medical 
journal, 1986, 293:6-8. 

Lip GYH, Kamath S, Hart RG. Clinical review: ABC 
of antithrombotic therapy. Antithrombotic therapy 
for cerebrovascular disorders. British medical journal, 
2002, 325:1161-1163. 



16 Deaths from stroke 

Map: Struck down 

Mortality and burden of disease estimates for 
countries provided by Colin Mathers (Evidence and 
Information for Policy, WHO) from analyses 
prepared for The World Health Report 2003. 

Predictors of death from stroke in Italy 

Mazza A, Pessina AC, Pavei A, Scarpa R, Tikhonoff 
V, Casiglia E. Predictors of stroke mortality in 
elderly people from the general population. The 
CArdiovascular STudy in the ELderly. European 
journal of epidemiologj, 2001, 17(12): 1097-1 104. 



Stroke compared with other causes of death; 
Wow: Worldwide... 

WHO. The World Health Report 2003: Shaping the 
future. Geneva, WHO, 2003, Annex Table 2:154-159. 

Wow: USA 

American Stroke Association 

http: / /www.strokeassociation.org/presenter.jhtml? 

identified 103 3 

Clipboard 

Lip GYH, Kamath S, Hart RG. Clinical review: ABC 
of antithrombotic therapy. Antithrombotic therapy 
for cerebrovascular disorders. British medical journal, 
2002, 325:1161-1163. 

Text 

The Stroke Association, United Kingdom. Stroke 

prevention programmes 

http : / / www. stroke, org. uk / Campaign / prevention . htm 

Mensah GA. Global burden of hypertension: good 
news and bad news. Cardiology clinics, 2002, 
20:181-186. 

Heller RF, Langhorne P, James E. Improving stroke 
outcomes: the benefits of increasing availability of 
technology. Bulletin of the WHO, 2000, 78:1337-1343. 

17 Economic costs 

Global costs of smoking 

WHO. World No Tobacco Day 2004 

http: / / www. who.int/tobacco/areas/communications 

/events/wntd/2004/en/ 

Global costs of heart disease medication 

Kmietowicz Z. News: WHO warns of heart disease 
threat to developing world. British medical journal, 
2002, 325:853. 

Global costs of diabetes 

International Diabetes Federation 

http://www.idf.org/home/index.cfmPunode 

=3B9691D3-C026-2FD3-87B7FAOB63432BA3 

Latin America and the Caribbean 

PAHO cites impact of diabetes in Latin America 
http: // www.unwire.org 



103 



USA, Australia, Europe 

Reuters. Asia-Pacific Type 2 Diabetes Policy Group: 
spread of diabetes in Asia alarms experts. South China 
Morning Post, 1 May 2002, 10. 

USA 

Runners beat around the Bush. Knight Ridder in 

o 

Washington. South China Morning Post, 
24 June 2002, 13. 

Diet, nutrition and the prevention of chronic diseases: 
report of a Joint WHO/FAO Expert Consultation. Geneva, 
WHO, 2003 (WHO Technical Report Series No. 
916):61. 

Elliot A. US food industry ensures that consumers 
are not told to eat less. British medical journal, 2003, 
327:1067. 

Reuters Health Information 2004. US. drug sales 
$216.4 billion in 2003 - IMS report 
http://www.medscape.com/viewarticle/469471? 
mpid=25157 

American Heart Association. Heart disease and stroke 
statistics 2004 update. Dallas, American Heart 
Association, 2003, Chapter 12:42. 

National Institute of Neurological Disorders and 

O 

Stroke. Questions and answers about stroke 

http : / / www. ninds. nih . gov / health_and_medical /pub 

s / stroke_backgrounder. htm 

United Kingdom 

Vlad I. Obesity costs UK economy 2 bn a year. 
British medical journal, 2003, 327:1308. 

Wise J. News: New clinical guidelines for stroke 
published. British medical journal, 2000, 320:823. 

Netherlands 

van Exel J, Koopmanschap MA, van Wijngaarden 
JDH, Scholte op Reimer WJM. Costs of stroke and 
stroke services: determinants of patient costs and a 
comparison of costs of regular care and care 
organised in stroke services. Cost effectiveness and 
resource allocation, 2003, 1:2 
http: / /www. resource-allocation, com/content/ 1/1/2 



Polder JJ, Meerding WJ, Koopmanschap MA, 
Bonneux L, van der Maas PJ. Cost of illness in the 
Netherlands 1994. Rotterdam, Instituut 
Maatschappelijke Gezondheidszorg [Institute for 
Medical Technology Assessment], Erasmus 
University, 1997 

http : / / www. ri vm . nl / kostenvanziekten / site_en / 
index.htm (in Dutch) 

Evers SMAA, Struijs JN, Ament AJHA, van 
Genugten MLL, Jager JC, van den Bos GAM. 
The disease impact, health care management, and costs of 
stroke in the Netherlands. Bilthoven, National Institute 
for Public Health and the Environment (RIVM), 
2002 (Report 282701001/2002). 

Singapore 

Venketasubramanian N, Yin A. Hospital costs for 
stroke care in Singapore. Cerebrovascular diseases, 
2000, 10:320-326. 

Price of weekly dose of medication 

WHO cardiovascular Disease Programme. Pilot survey 

O J 

on cost of cardiovascular drugs 2003 (unpublished data). 

The cost of risk factors 

Liu K, Daviglus ML, Van LJ, Garside DB, Greenland 
P, Manheim LM, Dyer AR, Stamler J. Cardiovascular 
disease (CVD) risk factor status earlier in adulthood 
and cumulative health care costs from age 65 to the 
point of death. Circulation, 2004, 108:IV-722. 

Lifetime costs of coronary heart disease 

Klever-Deichert G, Hinzpeter B, Hunsche E, 
Lauterbach KW. Zeitschriftfur Kardiologie, 1999, 
88:991-1000. 

Expenditure on cardiovascular medications 

Dickson M, Jacobzone S. Pharmaceutical use and 
expenditure for cardiovascular disease and stroke: a 
study of 1 2 OECD countries. Paris, Organisation for 
Economic Co-operation and Development, 2003 
(OECD Health working papers, 
DELSA/ELSA/WD/HEA(2003)1), Table 1. 

Wow: Aspirin 

Ebrahim S. Cost-effectiveness of stroke prevention. 
British medical bulletin, 2000, 56:557-570. 



104 



PART 4 ACTION 

18 Research 

Map: CVD research publications; Regional 
research 

Mendis S, Yach D, Benpoa R. Narvaez D, Zhang X. 

o o 

Research gap in cardiovascular disease in developing 
countries. Lancet, 2003, 361:2246-2247. 

Clinical trials 

Search by authors, 24 February 2004. 

Research funding by the National Institute of 
Health in the USA 

United States Department of Health and Human 
Services. National Institutes of Health. Estimates of 
funding Jbr various diseases, conditions, research areas 
http : / / www. nih . gov / ne ws / fundingresearchareas . htm 

Wow: United Kingdom 

Roth well PM. The high cost of not funding stroke 
research: a comparison with heart disease and cancer. 
Lancet, 2001, 357(9268): 1612-1616 (review). 

Bennett R, Burden S. UK funding for stroke 
research. Lancet, 2001, 358:1275 (correspondence). 

Clipboard 

Mendis S, Yach D, Bengoa R, Narvaez D, Zhang X. 
Research gap in cardiovascular disease in developing 
countries. Lancet, 2003, 361:2246-2247. 

WHO. The World Health Report 1 999: Making a 
difference. Geneva, WHO, 1999, Annex Table 3:108 

Text 

Baris E, Waverley Brigden L, Prindiville J, da Costa e 
Silva VL, Hatai C, Chandiwana S. Research priorities 
for tobacco control in developing countries: a 
regional approach to a global consultative process. 
Tobacco control, 2000, 9:217-23. 

Tunstall-Pedoe H, ed. MONICA monograph and 
multimedia sourcebook. Prepared by Tunstall-Pedoe H, 
Kuulasmaa K, Tolonen H, Davidson M, Mendis S 
with 64 other contributors for The WHO MONICA 
Project. Geneva, WHO, 2003. 



20 Prevention: personal choices and 
actions 

Personal choices in lifestyles and behaviour; 
Personal actions for safeguarding 
cardiovascular health 

Bulletin of the WHO, 1999. 

Young people 

Kavey RW, Daniels SR, Lauer RM, Atkins DL, 
Hayman LL, Taubert K. American Heart Association 
guidelines for primary prevention of atherosclerotic 
cardiovascular disease beginning in childhood. 
Circulation, 2003, 107:1562. 

Eat fruit and cereals 

Pereira MA, O'Reilly E, Augustsson K et al. Dietary 
fiber and risk of coronary heart disease. A pooled 
analysis of cohort studies. Archives of internal medicine, 
2004, 164:370-376 

http://archinte.ama-assn.org/cgi/content/abstract/ 
164/4/370 

The benefits of stopping smoking 

American Lung Association. When smokers quit, 
within twenty minutes of smoking that last cigarette 
the body begins a series of changes 
http: //www.lungusa.org/tobacco/quit_ben. html 

Wow: USA; Clipboard: Burning calories 

New "food pyramid" to address obesity epidemic. 
Reuters Health Information 2004 
http: / /www.lifetimefitness.com/health_info/index.c 
fm?strWebAction=health_article&intArticleId= 1 384 

Wow: Japan 

Schnirring L. Can exercise gadgets motivate patients? 

The physician and sportsmedicine, news briefs, 

2001, 29(1) 

http : / / www. physspor tsmed . com / issues / 200 1 / 

01_01 /news. htm 

Wow: Compared with less active... 

HeartBytes. Reduce heart disease risk: encourage and 

prescribe exercise for your patients. Medscape 

cardiology, 2004, 8(1) 

http : / / w w w. medscape . com / viewar ticle / 470 115? 

mpid=25341 



105 



Wow: People with low fitness... 

Carnethon MR, Gidding SS, Nehgme R, Sidney S, 
Jacobs DR Jr, Liu K. Cardiorespiratory fitness in 
young adulthood and the development of 
cardiovascular disease risk factors. Journal of the 
American Medical Association, 2003, 290(23):3092-100. 

Clipboard: For people with diabetes... 

Standards of medical care in diabetes. Diabetes care, 
2004, 27(Suppl 1):S1S-3S. 

Bilous R. Blood pressure control in type 2 diabetes 
what does the United Kingdom Prospective Diabetes 
Study (PDS) tell us? Nephrohgj dialysis and 
transplantation, 1999, 14:2562 2564. 

Clipboard: Reducing salt intake... 

He FJ, MacGregor GA. How far should salt intake be 
reduced? Hypertension, 2003, 42(6): 1093-9. 

Text 

O'Keefe JH Jr, Cordain L. Cardiovascular disease 
resulting from a diet and lifestyle at odds with our 
Paleolithic genome: how to become a 21st-century 
hunter-gatherer. Mayo Clinics proceedings, 2004, 
79:101-108. 

Carlsson CM, Stein JH. Cardiovascular disease and 
the aging woman: overcoming barriers to lifestyle 

o o o J 

changes. Current women's health report, 2002, 
2:366-372. 



Wows: Finland; Japan; New Zealand; 
Mauritius 

World Health Report 2002: reducing risks, 
promoting healthy life. Cardiovascular death and 
disability can be reduced more than 50%. Press 
Release WHO 783. 17 October 2002:6. 

Clipboard 

Institute of Medicine. Crossing the quality chasm: a new 
health system Jor the list Century. Washington, DC, 
National Academy Press, 2001 
http://books.nap.edu/books/0309072808/html/ 
1 .html#pagetop 

Text 

Mendis S. Role of governments in improving 
prevention of cardiovascular disease. Global Symposium 
on Cardiovascular Prevention, Marbella, Spain, 
11-13 April 2003. 

Salim Y. Two decades of progress in preventing 
vascular disease. Lancet, 2002, 360 
http://www.thelancet.com/journal/vol360/iss9326 
/full/Han. 360. 9326. editorial and re view. 2 1674.1 



22 Health education 

Map: World Heart Day 

World Heart Federation. World Heart Day 

http : / / www. worldhear tday. com / news / news . asp? 

Page=HeartNews# 



21 Prevention: population and 
systems approaches 

Noncommunicable disease prevention and 
control; Availability of equipment; Medical 
professionals; Antihypertensive drugs 

Alwan A, Maclean D, Mandil A. Assessment of national 
capacity Jor noncommunicable disease prevention and control; 
the report of a global survey. Geneva, WHO, 2001 . 

Use of medications in stroke and coronary 
heart disease 

Gaps in secondary prevention of myocardial 
infarction and stroke: WHO study on Prevention of 
REcurrences of Myocardial Infarction and StrokE 
(WHO-PREMISE) in low and middle income 
countries. WHO-PREMISE (Phase I) Study Group. 



World Heart Day: themes; activities; 
Evaluation of 

World Heart Day, A World Heart Federation 
enterprise promoting the prevention of heart disease 
and stroke across the world. Circulation, 2003, 
108:1038-1040. 

Grizeau-Clemens D. Evaluation of 2001 World Heart 
Day coverage. World Heart Federation, 2003. 

Giving up smoking: International Quit and 
Win 

Vartiainen ER, Project Manager, International 
Quit&Win, personal communication, 
20 January 2004. 



106 



23 Policies and legislation 

Map: Smoke-free workplaces 

Shafcy O, Dolwick S, Guindon GE, eds. Tobacco 
control country profiles 2003. Atlanta, GA, American 
Cancer Society, WHO, International Union Against 
Cancer, 2003. 

Cardiovascular disease plans worldwide; 
Legislation 

Policy data from: WHO. Capacity for NCD 
prevention and control survey 2001 . Assessment of 
national capacity for noncommunicable disease prevention 
and control. The report of a global survey. Geneva, 
WHO, 2001. 

Wow: 2002 USA 

Sargent RP, Shcpard RM, Glantz SA. Reduced 
incidence of admissions for myocardial infarction 
associated with public smoking ban: before and after 
study. British medical journal, 2004, 328:977-980. 



24 Treatment 

Cardiac rehabilitation; Patients reaching 
blood pressure and blood cholesterol goals 
during treatment 

EUROASPIRE II Study Group (2001). Lifestyle and 
risk factor management and use of drug therapies in 
coronary patients from 1 5 countries. Principal results 
from EUROASPIRE II Euro Heart Survey 
Programme. European heart journal, 2001, 
22:554-572. 

Simple secondary prevention medication 
treatments 

Yusuf S. Two decades of progress in preventing 
vascular disease. Lancet, 2002, 360:23 
http : / / www. thelancet . com 

Diabetes treatment 

Ustun TB, Chatterji S, Mechbal A, Murray CJL, 
WHS Collaborating Groups. The World Health Surveys 
in Health Systems Performance Assessment: debates, methods 
and empiricism. Murray CJL and Evans DB, eds, 
Geneva, WHO, 2003. 



Trends in cardiovascular operations and 
procedures in the USA 

American Heart Association. Heart disease and stroke 
statistics - 2004 update. Dallas, American Heart 
Association, 2003. 

Wow: Proportion of people... 

Mensah GA. The global burden of hypertension: 
good news and bad news. Cardiology clinics, 2002, 
20(2):181-185 

Wolf-Maier K, Cooper RS, Banegas JR et al. 
Hypertension prevalence and blood pressure levels in 
6 European countries, Canada, and the United 
States. Journal of the American Medical Association, 
2003, 289(18):2363-2369. 

Wow: In the USA, only 24%... 
Ford ES, Mokdad AH, Giles WH, Mensah GA. 
Serum total cholesterol concentrations and 
awareness, treatment, and control of 
hypercholesterolemia among US adults: findings 
from the National Health and Nutrition Examination 
Survey, 1999 to 2000. Circulation, 2003, 
107(17):2185-2189. 

Text 

Gunn J, Grossman D, Grech ED, Cumberland D. 
New developments in percutaneous coronary 
intervention. British medical journal, 2003, 
327(7407): 150-1 5 3. 

Mensah GA. Eliminating health disparities: the time 
for action is now. Ethnicity and disease, 2002, 



PART 5 THE FUTURE AND 
THE PAST 

25 Future 

DALYs; Deaths 

WHO (2004). Unpublished projections from 2000 
baseline, prepared for The World Health Report 2002, 
using projection methods developed by Murray CJL, 
Lopez AD. The global burden of disease. Boston, 
Harvard School of Public Health, 1996, Chapter 
7:325-395. 



107 



Risk factors 

Mackay J, Eriksen M. The tobacco atlas. Geneva, 
WHO, 2002:90-91. 

Wild S, Roglic G, Green A, Sicree R, King H. 

o o 

Global prevalence of diabetes. Estimates for the year 
2000 and projections for 2030. Diabetes care, 2004, 
27:1047-1053. 

Amos AF, McCarty DJ, Zimmet P. The rising global 
burden of diabetes and its complications: estimates 
and projections to the year 2010. Diabetes medicine, 
1997, 14(Suppl5):Sl-S5. 

Collins R, Clinical Trial Service Unit, University of 
Oxford, England, personal communication, 
6 January 2004. 

Economic costs 

REUTERS in Washington. United States: US obesity 
weighs heavy on health costs. South China Morning Post, 
10 March 2004, A12 (study by Rand Corporation). 

Action 

Guttmacher AE, Collins FS. Genomic medicine: 
a primer. New England journal of medicine, 2002, 
347:1512-1550. 

Wolf CR, Smith G, Smith RL. Science, medicine, 
and the future: pharmacogenetics. British medical 
journal, 2000, 320:987-990. 

Mackay J, Eriksen M. The tobacco atlas. Geneva, 
WHO, 2002:90-91. 

Treatment 

Pearson I. Atlas of the future. New York, Macmillan, 
1998:32-33. 

American Federation for Aging Research. What is the 
future of heart disease research likely to tell us? 

http://www.infoa2inp.orp/d-heart-l 1 -future. html 

r o o o 

Roden DM. Cardiovascular pharmacogenomics. 
Circulation, 2003, 108:3071 3074. 

Grossman D. Science, medicine, and the future. The 
future of the management of ischaemic heart disease. 
British medical journal, 1997, 314:356-359. 



Wald NI, Law MR. A strategy to reduce 

J ' c>j 

cardiovascular disease by more than 80%. 
British medical journal, 2003, 326:1419. 

Collins R, Clinical Trial Service Unit, University of 
Oxford, England, personal communication, 
6 January 2004. 

Text 

Rodpers A, Lawes C. MacMahon S. Reducing the 

o o 

global burden of blood pressure-related cardiovascular 
disease. Hypertension, 2000, 18(1 Suppl):S3 6. 

Lawes CM, Bennett DA, Feipin VL, Rodpers A. 

to o 

Blood pressure and stroke: an overview of published 
reviews. Stroke, 2004, 35(3):776-85. 

Milestones in knowledge of heart 
and vascular disorders 

Major sources 

Baddarni K. Historic aspects of cardiology 

http: / / www.geocities.com/baddarni/Cardiology- 

History.html 

Weisse AB. Heart to heart: the twentieth century battle 
against cardiac disease: an oral history. London, USA, 
Rutgers University Press, 2002. 

Stamler J. Lectures on preventive cardiology. New York, 
Grune & Stratton, 1967 (cited in Vance DE, van den 
Bosch H. Cholesterol in the year 2000. Biochemica et 
biophysica acta, 2000, 1529:1 8 

Wan S, Yim APC. The evolution of cardiovascular 
surgery in China. Annals of thoracic surgery, 2003, 
76:2147-55. 

A timeline of milestones from The Framingham 
Heart Study 
http://www.framingham.com/heart/timeline.htm 

Schooler C, Farquhar JW, Fortmann SP, Flora JA. 
Synthesis of findings and issues from community 
prevention trials. Annals of epidemiology, 1997, 
S7:S54-68. 



108 



Useful contacts 



World Health Organization 

http://www.who.int 

Cardiovascular disease: 

http://www5.who.int/cardiovascular iliseasfs/ 
Diabetes: 

http:// www. who. int /health_topicsAliabetes_mellitus /en/ 
Diet: 

http: // vvwvv. who.int/health_topics/dict/en/ 
Nutrition: 

http:// www. who. int /health_topics/ nutrition /en/ 
( )l>r-.it\ : 

http: //www. who. int/health_topics/obesity/en/ 
Public Health Surveillance: 

http: / / www. w ho. int / health_topics / public_hcalth_sur veillance /en / 
Tobacco Free Initiative: 

http://ww-w.who.int/tobacco/en/ 

Centers for Disease Control and Prevention, USA 

http://www.cdc.gov/ 

Cardiovascular Health Program: 

http : / / www. cdc . gov / cvh / 
Nutrition and Physical Activity Program: 

http://www.cdc.gov/nccdphp/dnpa/ 
Tobacco Program: 

to 

http : / / www. cdc . gov / tobacco / 
Diabetes Program: 

http: // www.cdc.gov/diabetes/ 
Laboratory Sciences Program: 

http://www.cdc.gov/nceh/dls/programs.htm 
Office of Global Health: 

http: // www.cdc.gov/ogh/ 
Behavioral Risk Factor Surveillance System: 

http: / /www.cdc.gov/brfss 
National Center for Health Statistics: 

http: / /www.cdc.gov/nchs 

International and Regional Organisations 

Asian Society for Cardiovascular Surgery: 

http: / / www.ascvs.org/ 

Association for European Paediatric Cardiology /Association 
Europeenne pour la Cardiologie Pediatrique: 

http : / / www. aepc . org / home . htm 
Brain Aneurysm Foundation: 

http : / / www. bafound . org 
Cairdes: http://www.cairdes.com 
CardioStart International Inc: 

http://www.cardiostart.com/ 
Cardiothoracic Surgery Network: 

http: / / www.ctsnet.org/ 
Chain of Hope: http://www.chainofhope.org 
Children's HeartLink: 

http: / /www.childrensheartlink.org/ 
Children's Hearts: http://www.childrenshearts.org.uk 
Clearinghouse for Tobacco Control (South East Asia): 

http://www.prn2.usm.my/pages/about.asp 
Coeurs pour Tous (Hearts for All): 

http : / / www. cptg. ch / fr / start . htm 
Congenital Heart Information Network: 

http: / /www. tchin.org/ 



Congress of Neurological Surgeons: 
to c> to 

http://www.neurosurgeon.org 
Consortium for Southeastern Hypertension Control (COSEHC): 

http://www.cosehc.org/ 

East Meets West: http://www.eastmcetswest.org 
Eastern Mediterranean Network on Heart Health, (EMNHH): 

http://emnhh.homestead.com/files/index.htm 
The Endocrine Society: http://www.endo-society.org/ 
European Association for Cardiothoracic Surgery: 

http://www.eacts.org/ 
European Heart Institute: 

http: / / www.european-academy.at 
European Heart Network: 

http://www.ehnheart.org/index2.asp 
EMASH European Medical Association on Smoking and Health: 

http: / /emash. globalink.org/ 
ENSH European Network for Smoke-free Hospitals: 

http://ensh.free.fr/ 
ENSP European Network for Smoking Prevention: 

http://www.ensp.org 
European Network of Young People and Tobacco: 

http://www.ktl.fi/enypat/ 
European Network of Quitlines: 

http://www.quitlines-conference.com/ 
European Society for Noninvasive Cardiovascular Dynamics: 

http://www2.mf.uni-lj.si/~esnicvd/ 
European Society of Cardiology: 

http: / /www. escardio.org/ 
European Society of Hypertension: 

http: / / www.eshonline.org/ 
European Stroke Initiative: 

http://www.eusi-stroke.com/index.shtml 
European Union of Non-smokers: 

http://www.globalink.org/tobacco/docs/eu-docs/uene.htm 
Framework Convention Alliance (FCA): 

http: / / www.fctc.org/ 
G8 Telematics Heart Health Project: 

http://www.med.mun.ca/g8hearthealth/ 
Gift of Life International Inc.: 

http://www.giftoflifeinternational.org/ 
Global Connection International: 

http : / / w w w. gci world . org 
Global Cardiovascular Infobase (in English and Spanish): 

http://www.cvdinfobase.ca/ 

Global Healing: http://www.globalhealing.org 
to r b to to 

Global Health Information Network: 

http: / / www.healthnet.org/ 
Global Partnerships for Tobacco Control: 

http: / / www.essentialaction.org/tobacco/ 
Globalink, UICC International Union against Cancer: 

http: // www.globalink.org/ 
Healing the Children: 

http://www.healingchildren.org 
Heart Care International: 

http: / /www. heartcareintl.org 
HeartGift Foundation: 

http://www.heartgift.org/index.html 
The Heart of a Child Foundation - Little Hearts on the Mend: 

http : / / www. littleheartsonthemend . org 
Heart-to-Heart International: 

http : / / www. hearttoheart . org/ 



109 



Heart-to-Heart International Children's Medical Alliance: 

http://www.heart-2-heart.org/ 
Initiative for Cardiovascular Health Research in Developing Countries: 

http://www.globalforumhealth.org/pages/index.asp? 
ThePage=page1_OOOS00040001_l.htm&Nav=OOOS00040001 
Inter American Heart Foundation: 

http : / / www. interamericanhear t . org 
Inter American Society of Cardiology (in Spanish and English): 

http :// www. soinca . org 
Inter-American Society of Hypertension: 

http://org.umc.edu/iash/homepage.htm: 

http://www.musc.edu/iash/generale.htm 
International Academy of Cardiology: 

http://www.cardiologyonline.com/ 
International Agency on Tobacco and Health (IATH): 

Email: admin@iath.org 

^~s o 

International Atherosclerosis Society: 

http : / / w ww.athero. org/ 
International Children's Heart Foundation: 

http://www.ichf.org/ 
International Children's Heart Fund: 

http://www.ichfund.org/ 
International Diabetes Federation: 

http: / / www.idf.org/ 
International Diabetes Institute, Australia: 

http :// www. diabetes . com . au / home . htm 
International Federation of Sports Medicine: 

http://www.fims.org/ 
International Hospital for Children (IHC): 

http: / / www.healachild.org 
International Network of Women against Tobacco (IN WAT): 

http://www.inwat.org/ 
International Network towards Smoke-Free Hospitals (INTSH): 

http://intsh.plobalink.org/ 
r o o 

International Non Governmental Coalition against Tobacco (INGCAT): 

http://www.ingcat.org/ 
r o o 

International Obesity Task Force: 

http://www.iotf.org/ 
International Pediatric Hypertension Association: 

http://www.pediatrichypertension.org/ 
International Society for Adult Congenital Cardiac Disease: 

http://www.isaccd.org/ 
International Society for Aging and Physical Activity: 

http://www.isapa.org/ 
International Society for Cardiovascular Surgery: 

http://www.vascsurg.org/doc/ 1 S76.html##.htm 
International Society for Heart Research: 

http : / / www. ishrworld . org/ 
International Society for Heart & Lung Transplantation: 

http://www.ishlt.org/ 
International Society for Minimally Invasive Cardiac Surgery: 

http://www.ismics.org/ 

International Society for the Prevention of Tobacco Induced Diseases 
(PTID): http://www.ptid.org 
International Society of Cardiovascular Ultrasound: 

http://www.iscu.org/ 
International Society of Hypertension: 

http://www.hypertension2004.com.br/ 
International Society of Nephrology: 

http: / / www.isn-online.org/ 
International Society on Hypertension in Blacks (ISHIB): 

http: //www.ishib.org/main/ishib_opcn. htm 
International Stroke Society: 

http://www.internationalstroke.org/index.php 
International Task Force for the Prevention of Coronary Heart Disease: 

http://www.chd-taskforce.de/ 



International Tobacco Evidence Network (ITEN): 

http : / / w w w. tobaccoevidence . net / 
The Internet Stroke Center: 

http://www.strokecenter.org/pat/organi7.ations.htm 
Legacy Foundation, tobacco document site: 

http://legacy.library.ucsf.edu/cgi/b/bib/bib-idx?g=tob 
Mediterranean Stroke Society: 

http://www.hsanmartino.liguria.it/cictus/med.htm 
OTAF L'Observatoire du Tabac en Afrique Francophone: 

http: / /otaf.globalink.org/ 

Physicians lor Peace: http://www.physiciansforpeace.org 
ProCOR: Conference on Cardiovascular Health: 

http://www.procor.org/ 
Project Hope: http://www.projecthope.org 
Project Kids Worldwide: 

http: / /www.projectkidsworldwide.org 
Project Open Hearts: http://www.poh.org 
Repace's site, especially on passive smoking (Jim Repace): 

http://www.repace.com/ 
Save A Child's Heart Foundation: 

http://www.saveachildsheart.com 
Society for Research on Nicotine and Tobacco (SRNT): 

http: / / www.srnt.org/ 
Smokescreen Action Network: 

http://www.smokescreen.org 
Southeast Asian Tobacco Control Alliance: 

http: / /www. tobaccofreeasia.net/ 
Stroke Awareness for Everyone: 

http://www.strokesafe.org/ 
Stroke Clubs International: 

Email: strokeclub@aol.com 
Stroke Net: 

http : / / www. strokenet . info /resources/ stroke / internationalsites. htm 
Surgeons of Hope Foundation: 

http : / / w w w. surgeonsofhope . org 
Tobacco, org : http : / / www. tobacco, org 
Tobacco Control journal: 

http : / / w w w. tobaccocontrol . com 

Tobacco Control Resource Center /Tobacco Products Liability Project 
(TCRC/TPLP): http://tobacco.neu.edu/ 
TCRC Tobacco Control Resource Centre, BMA, UK: 

http: / /www.tobacco-control.org/ 
Tobacco Control Supersite: 

http : / / www. health .usyd.edu.au/ tobacco / 
Tobacco Documents Online (TDO, Smokescreen: 

http: / /www. tobaccodocuments.org 
Tobaccopedia: 

http: / / TobaccoPedia.org 

Treatobacco Database & Educational Resource for Treatment of 
Tobacco Dependence: 

http://www.treatobacco.net/ 
World Federation of Neurology: 

http://www.wfneurology.org/ 
World Heart Federation: 

http://www.worldheart.org/ 
World Heart Foundation: 

http://www.world-heart.org/ 
World Hypertension League: 

http ://www.mco.edu/ org / whl / 
World Kidney Foundation: 

http : / / www. worldkidneyfund .org/ 
World Medical Association: 

http://www.wma.net/ 



110 



Index 



activity see physical activity and 

inactivity 

ACE inhibitors 40, 71,92 
age, advancing 19, 25, 42 
alcohol use 19, 24-25 
ancurysm see aortic aneurysm and 

dissection 

angina pectoris 32, 77, 78 
angioplasty 71, 79, 92 
anticoagulant 92 
antihypertensive drugs 65 
aortic aneurysm and dissection 19, 32 
arrhvthmia 71 , 92 
arteriosclerosis 76, 92 
artificial body parts 71 , 75, 80 
arterial disease, peripheral 19, 32, 76 
aspirin 55, 65, 71, 78,79, 80, 81 
atherosclerosis 26, 31, 32, 42, 77, 92 
atrial fibrillation 19, 20, 50, 52, 78, 

80, 92 

beta-blockers 71 
blood clotting 

O 

disorders 19, 25, 32; see also 

stroke 

treatment of 80, 81 
blood pressure 28-29, 32, 48, 

62-63, 66, 70, 77, 78, 80, 92 

high 19, 24-25, 26, 28-29, 32, 

34, 40, 42, 50, 52, 63, 64, 70, 

79, 93 

see also hypertension and 

hypertensive heart disease 
blood sugar levels 62 
body mass index (BMI) 36-37, 92 
brain tumours, vascular 19 
bypass see coronary artery bypass 

surgery 

cardiac 

defibrillation71,78, 79 

pacemakers 71, 78, 79 

rehabilitation 70 

see also coronary and heart 
cardiovascular disease (CVD) 92 

deaths from 18, 74 

disability-adjusted life years 

(DALYs) 74 

investigations for 75 

economic costs of 5 5 

medication for 65, 71, 75, 77 



prevention of 62 63, 6465, 66- 

67, 68, 80, 81 

research into 58-59, 75 

risk factors 24 43 

surgery 70-71, 75, 78, 79, 80, 81 

types of 18-19 
carotid 

endarterectomy 71 

stenosis 52, 92 
cars see motor vehicles 
Centers for Disease Control and 

Prevention (USA) 60 
cerebrovascular disease see stroke 
childbirth 19 
children and youth 2021, 25, 

26-27, 38, 51, 62, 66 
cholesterol 19, 24-25, 30-31, 40, 

42,48, 62, 65, 70-71, 77, 79, 

80, 81, 92 

HDL (high-density lipoprotein) 

25, 30, 32,42, 80, 93 

LDL (low-density lipoprotein) 

25, 30, 32, 80, 93 

plaques 32, 77, 92 
cigarettes see tobacco use 
clotting see blood clotting 
contraceptive, oral 19, 25, 42, 50 
coronary 

artery bypass surgery 71 , 92 

artery disease 79 

artery spasm 32 

stent71, 80, 93 

see also cardiac and heart 
coronary heart disease 19, 32, 

34-35, 40, 52, 92 

burden 4647 

deaths from 1819, 35, 46-47, 

48-49, 74 

disability-adjusted life years 

(DALYs) 46-4-7, 74 

economic costs of 55 

medication for 65, 71, 81 

prevention of 48 

research into 5859 

risk factors 19, 79 
costs see economic costs 

deaths from 

cardiovascular disease 18, 74 
coronary heart disease 1819, 35, 
48-49, 74 



diabetes mellitus 48 

hypertensive heart disease 18, 48 

inflammatory heart disease 1 8 

physical inactivity 35 

rheumatic heart disease 

18, 20-21 

stroke 18-19, 48, 50-51, 52-53, 

74 

tobacco use 74 
deep venous thrombosis 1 9 
diabetes mellitus 19, 25, 34, 38-39, 

40-41,42,48, 52, 63, 64, 75, 

80, 81,92 

deaths from 48 

economic costs of 54 

predicted number of people with 

75 

research into 58-59 

treatment of 7 1 

type 1 diabetes 38 

type 2 diabetes 26, 36, 38, 54 
diet 19, 24-25, 26, 28, 36, 42, 48, 

52, 62-63, 64, 66, 77, 80; 

see also food 
digitalis 77 
disability-adjusted life years (DALYs) 

46-4-7, 50-51, 74, 92 

economic costs 5455, 75, 92, 93 
education 

health 66 67 

level of 19, 28, 40,41 
electrocardiogram (ECG) 78, 79 
embolism see pulmonary embolism 
ethnicity and race 25, 42 

food 30, 36, 62 
cereals 63 
fast 68 

fruit and vegetables 24, 28, 36, 
62-63, 64 
labelling of 65, 68 
legislation on 69 

O 

processed 28 
see also diet 
future 74-75 

gender differences 25, 27, 2829, 
32-33,42-43,81; 
see also women 



111 



genetic 

disposition 19, 25,48, 81 

science 75 

therapy 8 1 

see also heredity 

HDL-cholesterol see cholesterol, 

HDL 
health see also education, health and 

mental health and public health 

and tobacco use, health warnings 
health care 

access to 40 

economic costs of 54 55 
heart 1 8 

attack 30, 32, 93 

catheterization 71, 78 

congenital disease 1 9 

failure, congestive 92 

inflammatory disease 1819, 81 

muscle 18-19, 77 

transplantation 71, 75, 79, 81 

tumours 19 

valves 19, 20, 71, 76, 79 

see also cardiac and coronary and 

hypertensive heart disease 
heredity 25, 42 see also genetic 
homocysteine levels in blood 

19, 25,93 
hormone replacement therapy 

19, 25,42-43 
hypertension 28 

see also blood pressure, high 
hypertensive heart disease 

deaths from 18, 48 

see also blood pressure, high 

inactivity see physical activity and 

inactivity 
International Conferences on 

Preventive Cardiology 60 
International Heart Health 

Conferences and Declarations 6 1 , 

64, 66-67, 81 

labelling see food 

LDL-cholesterol see cholesterol, LDL 

left ventricular hypertrophy 25 

legislation 68-69 

Iipids25, 26, 30-31, 34, 52,93 

lowering medication 40, 71 

see also cholesterol 



medical professionals 42, 62, 65 
medication 42, 54-55, 62, 65, 71 , 75, 

77,81 

mental health 19, 25 
MET (metabolic equivalent) 35, 93 
motor vehicles 3435 
myocardial infarction see heart attack 

nutrition see food and diet 

obesity 19, 24-25, 26, 34, 36-37, 
41,42, 62, 65, 66, 79, 80, 93 
economic costs of 5455, 75 

open heart surgery 71,79 

operations 71 

organizations 6061 

physical activity and inactivity 
19, 24-25, 26-27, 28, 34-35, 
40, 42-4-3, 48, 54, 62-63, 66, 
78,79,80,81,93 

policies 6869 

poverty 19, 20 

prevention see cardiovascular disease, 
prevention of 

public health 

initiatives 6465 
policy 68-69 

pulmonary embolism 1 9 

Quit and Win 67 

race see ethnicity and race 
rehabilitation 70 
research 58^59, 75, 76-81 
rheumatic fever 20, 78, 93 
rheumatic heart disease 19, 20 21 , 93 

deaths from 18, 20-21 
risk factors 19, 24-43, 55, 62-63, 

66-67, 79, 80 

salt intake 28, 52, 63, 65 
schools 

health education in 66 
smoking see tobacco use 
socioeconomic status 25, 34, 4041, 

52 

sphygmomanometer 78 
statins 65, 81 
stent see coronary stent 
streptococcal infection 19, 20 
stress 25, 34, 40, 42, 62, 77 
stroke 19, 20, 30, 32, 34, 50-53, 

76, 78, 80, 93 

burden 50-5 1 



carotid stenosis 52 
deaths from 18-19,48, 50-51, 
52-53, 74 

disability-adjusted life years 
(DALYs) 505 1 
economic costs of 5455 
medication for 65, 71 , 80 
research into 58-59 
risk factors 19, 63, 79, 80 
young people 5 1 

surgery see coronary artery bypass 
surgery and open heart surgery 
and cardiovascular disease surgery 

o J 

technology 70-71 , 75, 77-81 
thrombosis see deep venous thrombosis 
tobacco use 19, 24-25, 26-27, 
32-33, 40-41, 42-4-3, 48, 50, 
52, 62, 74, 79, 80, 81 
deaths from 74 
economic costs of 5455 
health warnings about 68 
knowledge of risks 3233 
legislation on 69 
passive smoking 32, 62 
prevalence of 27, 33, 75 
quitting smoking 33, 62 63, 67 
smoke-free areas 6869, 81 
transplant see heart transplantation 
treatment 64-65, 70-71, 75, 80 
triglycerides 30, 42, 80, 93 

United Nations Conventions and 
Goals 75 

vascular disease, peripheral 92 

women 25, 28-29, 30, 32-33, 42-43 
World Congresses of Cardiology 60 
World Health Assembly 68, 81 
World Health Organization 60-6 1 , 
79, 81 

Framework Convention on 
Tobacco Control 68-69, 81 
Global School Health Initiative 66 
Global School-based Student 
Health Survey 66 
Global Strategy on Diet, Physical 
Activity and Health 8 1 
World Heart Days 66-67, 81 
World Heart Federation 60, 66-67, 

79 
World Stroke Congresses 61 

youth see children and youth 



112 



"Heart disease and stroke rob too many people of 

precious years of quality life. This one-of-a-kind 

atlas serves as a key resource for those on the 

frontlines of health. " Dr Julie Gerberding, Director, 

Centers for Disease Control and Prevention, Atlanta, Georgia, USA 

"We applaud the authors for producing such a 
comprehensive document in such a user-friendly 

format." World Heart Federation 



Heart disease can no longer be seen as the problem of overworked, 
overweight middle-aged men; in today's world, we are all - women 
and children too - at risk. One in three deaths worldwide 
-17 million deaths each year - is due to cardiovascular disease. 



These full-colour maps and graphics illustrate 
the wide range of issues relating to this global 
epidemic, including: 

Risk factors: 

high blood pressure, tobacco, inactivity, 
obesity, lipids, diabetes 

Women, childhood and youth 



The global burden of 
cardiovascular disease 

Research 
Prevention 

Policies and legislation 
Treatment 
The future 







Trends in cholesterol levels in Beijing, 

Mean total cholesterol in people aged 25-64 year 

1984- 1999 

mmol/l 




Men 

4.15 

* 
1984 



Front cover photograph: 

Amy, Hong Kong Guy Nowell 

Back cover photographs: 
Cardiology operation, Mauritius e 
WHO/Harry Anenden; 
Man selling vegetables, India 
WHO/ Pierre Virot; Man on bencl 
iStock/Tomaz Levstek; Woman 
and girl buying sweets, India * 
WHO/Pierre Virot; Bowl of rice 
Hemera Photo-Objects 

Cover design: Corinne Pearlman 



o 

m 



a myriad edition 

ISBN 92 4 156276 8 



World Health Organization 

www.who.int 




9 789241 562768